The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction.
Which intervention should the PN implement first?
Administer oxygen at 10 L/face mask.
Discontinue oxytocin infusion.
Observe perineum for cord prolapse.
Reposition the client laterally.
The Correct Answer is D
Fetal heart rate (FHR) is one of the essential indicators of fetal well-being during labor. A fall in FHR following each contraction is known as recurrent deceleration and can be an indication of fetal distress. In this case, the PN should first reposition the client laterally, as this may help to alleviate compression of the umbilical cord and improve fetal oxygenation.
A. Administering oxygen at 10 L/face mask may be necessary, but it is not the first intervention to be implemented in this scenario.
B. Discontinuing oxytocin infusion may be necessary, but it is not the first intervention to be implemented in this scenario.
C. Observing perineum for cord prolapse is not necessary in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Repeated visits to multiple emergency departments for various injuries or complaints can be a red flag for possible child abuse. The other options may indicate other issues or concerns, but they do not provide as much reason to suspect child abuse as the history of repeated visits to different emergency departments. It is important for healthcare providers to remain vigilant for signs of child abuse and to report any suspicions to the appropriate authorities.
Correct Answer is C
Explanation
Albuminuria, or the presence of albumin in the urine, is an early sign of relapse in a toddler with minimal change nephrotic syndrome (MCNS) who has been treated with corticosteroids. MCNS is a kidney disorder that can cause the body to excrete too much protein in the urine, leading to albuminuria. The practical nurse should recognize this finding as an early sign of relapse and take appropriate action to manage the child's condition.
The other answers are incorrect because they are not directly related to the early signs of relapse in a toddler with minimal change nephrotic syndrome (MCNS) who has been treated with corticosteroids.
- Increased thirst is not a known early sign of relapse in MCNS.
- Tachypnea, or rapid breathing, is not a known early sign of relapse in MCNS.
- A rounded face can be a side effect of corticosteroid treatment, but it is not an early sign of relapse in MCNS.
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