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

Administer oxygen via facemask.

Change the client’s position.

Turn off the oxytocin infusion.

Assess cervical dilatation.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.

Choice B rationale

Changing the client’s position 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.

Choice C rationale

Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.

Choice D rationale

Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.

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Correct Answer is ["50"]

Explanation

To calculate the rate at which the infusion pump should be set, we need to determine how many mL of the solution contain 2 grams of magnesium sulfate.

Step 1: First, we find out how many grams of magnesium sulfate are in 1 mL of the solution. The IV bag contains 20 grams of magnesium sulfate in 500 mL, so we divide 20 grams by 500 mL to get the amount of magnesium sulfate per mL: 20 grams ÷ 500 mL = 0.04 grams/mL

Step 2: Next, we find out how many mL contain 2 grams of magnesium sulfate.

We divide 2 grams by the amount of magnesium sulfate per mL: 2 grams ÷ 0.04 grams/mL = 50 mL Therefore, the nurse should set the infusion pump to deliver 50 mL per hour.

A. Initiate phototherapy for the newborn. B. Review the mother’s medical records for blood type and Rh factor. C. Measure bilirubin levels using transcutaneous bilirubinometry. D. Evaluate the results of the cord blood Coomb’s test.

Correct Answer is C

Explanation

Choice A rationale

Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.

Choice B rationale

Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.

Choice C rationale

Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately

measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.

Choice D rationale

Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["50"]

Explanation

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

Correct Answer is C

Explanation

Which type of anesthesia, when used with a laboring client, results in a loss of sensation confined to the vagina and perineum?

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