The nurse is evaluating the fetal monitor tracing of the patient who is in active labor.
Suddenly, the nurse sees the FHR drop from its baseline of 125 down to 80. The nurse repositions the mother, provides oxygen, increases intravenous fluids, and performs a vaginal exam.
The cervix has not changed.
Two minutes have passed, and the fetal heart rate remains in the 70s.
What additional nursing measures should the nurse take?
Call for help and notify the care provider.
Immediately get help and have the operating room ready.
Start Pitocin.
Insert a Foley catheter.
Repeat the uterine resuscitation.
Correct Answer : A,B
Choice A rationale
Calling for help and notifying the care provider ensures that expert medical assistance is available promptly for any emergency interventions required.
Choice B rationale
Getting help and preparing the operating room ensures readiness for an immediate cesarean section if fetal distress persists and the situation does not improve rapidly.
Choice C rationale
Starting Pitocin is inappropriate during fetal distress as it may further stress the fetus by increasing contraction frequency and intensity, potentially worsening the situation.
Choice D rationale
Inserting a Foley catheter does not address the immediate concern of fetal distress and would not provide immediate benefit in improving fetal heart rate.
Choice E rationale
Repeating uterine resuscitation measures (e.g., repositioning, oxygen, IV fluids) is essential, but if they are ineffective, additional interventions, such as preparing for possible surgical delivery, are needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Erythromycin ophthalmic ointment does not prevent the infant's eyelids from sticking together; it is not its primary purpose and does not aid in vision enhancement.
Choice B rationale
Erythromycin ophthalmic ointment is used to prevent gonorrheal infection acquired during birth, protecting the infant’s eyes from potential infection that can cause blindness.
Choice C rationale
Erythromycin does not prevent exudate from invading the tear ducts, nor does it lead to dry eyes. Its primary function is antimicrobial.
Choice D rationale
Erythromycin ophthalmic ointment is not specific to Staphylococcus and does not directly destroy infectious exudate. It prevents infections like gonorrhea.
Correct Answer is A
Explanation
Choice A rationale
Mild contractions and minimal cervical dilation suggest false labor. Administering a sedative helps the patient rest and wait for true labor onset. Sedatives can include sleep-inducing medications.
Choice B rationale
Cesarean birth is not indicated for a primigravida with mild contractions and minimal cervical dilation. This intervention is reserved for more serious obstetric complications.
Choice C rationale
Extended observation is unnecessary for mild contractions and unchanged cervical status. It is more appropriate for patients showing signs of true labor or complications.
Choice D rationale
True labor onset requires regular, increasing intensity contractions and cervical changes. Discharging the patient allows her to await true labor onset at home comfortably.
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