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 A
Explanation
The fact that the patient is being treated for depression and is currently taking an antidepressant medication suggests that his loss of interest in sexual intimacy may be related to his medication. Certain antidepressants can cause sexual dysfunction, including decreased libido.
Therefore, obtaining a list of medications currently being taken (A) is the most important information for the PN to obtain. While marital discord (B), frequency of sexual activity (C), and alcohol consumption (D) may be relevant information, they are not as directly related to the patient's current complaint as his medication use.
Correct Answer is A
Explanation
The practical nurse (PN) should obtain a serum glucose level to assess the client's blood sugar level, which can help to determine if the client is experiencing hyperglycemia or diabetic ketoacidosis (DKA). Anorexia, drowsiness, and polydipsia, along with the reported frequent urination and bedwetting, are symptoms of hyperglycemia or DKA.
Offering age-appropriate toys (B) or suggesting diapers for bedtime use (C) are not appropriate actions for the PN to take in this situation.
Bringing orange juice and crackers (D) may help to increase the client's blood sugar level in the short term, but it does not address the underlying issue and may exacerbate the client's symptoms if she is experiencing hyperglycemia or DKA.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today