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.

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Correct Answer is A

Explanation

The diaphragm must be refitted after childbirth:
This statement is correct. After childbirth, especially vaginal delivery, there can be changes in the size and tone of the vagina. Therefore, it's important to be refitted for a diaphragm after giving birth.

The most effective form of contraception is a diaphragm:
This statement is not accurate. While the diaphragm is a reversible and user-controlled method, its effectiveness can vary. It requires correct and consistent use to be effective.

The diaphragm should be inserted 2 to 4 hours before intercourse:
This statement is partially correct. The diaphragm should be inserted no more than 2 hours before intercourse and should be left in place for at least 6 hours after intercourse.

Vaseline lubricant can be used when inserting the diaphragm:
This statement is incorrect. Oil-based lubricants, including Vaseline, can damage latex diaphragms. Water-based lubricants are recommended for use with diaphragms

A. Place client in a negative pressure room B. Implement droplet precautions C. Encourage the mother to bottle-feed D. Give antiviral medication intravenously E. Use standard precautions

Correct Answer is ["C","D","E"]

Explanation

A. Place client in a negative pressure room:HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.

B. Implement droplet precautions:HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.

C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.

D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).

E. Use standard precautions:Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?

Correct Answer is A

Explanation

A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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