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

Answer and Explanation

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.

VEAL CHOP Nursing, What is the VEAL CHOP Method? - LevelUpRN

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Correct Answer is D

Explanation

A. Discuss options for intrauterine surgical correction of congenital defects:At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.

B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated:While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.

C. Reassure the client that the AFP results are likely to be a false reading:Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.

D. Explain that a sonogram should be scheduled for definitive results:An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.

A. Level of pain sensation. B. Variability of fetal heart rate C. Maternal blood pressure D. Station of presenting part

Correct Answer is C

Explanation

Level of pain sensation:

This is important for assessing the effectiveness of the epidural anesthesia, but it's not the most critical assessment immediately after administration.

Variability of fetal heart rate:

Monitoring fetal heart rate is always important, but immediately following epidural administration, the maternal blood pressure is a more immediate concern.

Maternal blood pressure:

This is the most critical assessment after epidural administration. Epidurals can cause a sudden drop in blood pressure, which may affect blood flow to the baby.

Station of presenting part:

The station of the presenting part (the position of the baby's head in relation to the ischial spines) is important for assessing progress in labor, but it's not the most crucial assessment immediately after epidural administration.

What Is An Adverse Effect Of Epidural Anesthesia

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The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Correct Answer is D

Explanation

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Correct Answer is C

Explanation

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