The nurse is caring for a laboring client. The nurse observes that there are variable decelerations. What is the nurse's priority action?

Assist the client to change positions

Promptly inform the primary care provider

Advocate for the client to have a vaginal examination

Continue to monitor the client and the fetal heart rate

Answer and Explanation

The Correct Answer is A

A.   Changing the client's position, especially if there's a cord compression causing variable decelerations, is a priority intervention to alleviate the decelerations.
B.   Informing the primary care provider is important, but immediate action to address the decelerations should be taken first.
C.   Vaginal examination is not the immediate priority when variable decelerations are observed; interventions to improve fetal oxygenation are more critical.
D.   Continuous monitoring is essential, but addressing the cause of the variable decelerations by changing the client's position is the immediate action.

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Correct Answer is D

Explanation

A. Absent variations would show no detectable fluctuations in the fetal heart rate.

B. Minimal variability would show minimal fluctuations in the fetal heart rate, with an amplitude range of less than 5 beats per minute.

C. Marked variability would show wide and pronounced fluctuations in the fetal heart rate, with an amplitude range greater than 25 beats per minute.
D. Fluctuations in the fetal heart rate are within a moderate range, between 6 and 25 beats per minute.

A. Place client on her left side B. Notify RN immediately C. Document the time and color of fluid D. Check fetal heart tones

Correct Answer is B

Explanation

A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.

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The nurse is caring for a laboring client. The nurse observes that there are variable decelerations. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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