The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?
Administer oxygen via facemask.
Turn off the oxytocin infusion
Assess cervical dilatation
Change the client's position
The Correct Answer is D
A. Administer oxygen via facemask: Oxygen administration is generally a step in managing fetal distress. However, when dealing with variable decelerations, the initial action involves repositioning the mother to alleviate potential cord compression, as variable decelerations are often due to compression of the umbilical cord.
B. Turn off the oxytocin infusion: If variable decelerations persist despite repositioning, it might be necessary to discontinue the oxytocin (Pitocin) infusion temporarily. Oxytocin can cause or exacerbate uterine hyperstimulation, which can contribute to fetal distress.
C. Assess cervical dilatation: Assessing cervical dilatation might be a part of the overall assessment but might not directly address the immediate issue of variable decelerations. However, it's essential to monitor the progress of labor as part of the broader assessment.
D. Change the client's position: This is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
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Related Questions
Correct Answer is D
Explanation
A. Epidural block: Epidural anesthesia is a regional anesthesia that blocks sensations in a specific region of the body. It is commonly used in labor and delivery to provide pain relief by injecting anesthetic medication into the epidural space, numbing the lower half of the body.
B. Saddle block: A saddle block, also known as a subarachnoid block, is a type of spinal anesthesia. It involves injecting anesthetic medication into the subarachnoid space, providing numbness to the lower half of the body, including the perineum.
C. Paracervical block: A paracervical block involves injecting a local anesthetic around the cervix. It is used to provide pain relief during certain medical procedures, such as cervical dilation or biopsy. It does not provide anesthesia to the entire perineum.
D. Pudendal block: A pudendal block involves injecting a local anesthetic into the pudendal nerve, which supplies sensation to the perineum. It is often used during the second stage of labor to provide localized pain relief during the delivery of the baby's head.
Correct Answer is B
Explanation
A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.
B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.
C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.
D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.
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