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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The best indicator to the practical nurse (PN) that the community bicycle safety education program was effective is that the number of students wearing bicycle helmets increased by 10%. Wearing a helmet while riding a bicycle is an important safety measure that can help prevent head injuries in the event of an accident. An increase in the number of students wearing helmets indicates that the program was successful in promoting this safety behavior. The other findings listed may also provide useful information about the effectiveness of the program, but the increase in helmet use is the most direct and measurable indicator of success.
Correct Answer is D
Explanation
The practical nurse (PN) should recognize that the client who is 2-weeks postpartum and presents with feelings of irritability, severe mood swings, and an irrational sense of her ability to keep her infant safe may be exhibiting symptoms of postpartum psychosis. Postpartum psychosis is a rare but serious condition that can develop after childbirth and is characterized by symptoms such as delusions, hallucinations, and severe mood swings. The client's belief that her infant is going to die and that there is nothing she can do to save her baby may indicate the presence of delusions. The PN should report these symptoms to the appropriate healthcare provider for further assessment and intervention.
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