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
If the client in active labor expresses a desire to empty her bladder and her vaginal exam is unchanged, the practical nurse (PN) should assist her up to the bathroom. An empty bladder can help facilitate labor progress.
Reviewing the fetal heart rate pattern (A) is important, but it is not the most appropriate action in response to the client's request to empty her bladder. Checking the perineum for changes in "show" or discharge (C) is also important, but it is not the most appropriate action in this situation. Obtaining a straight catheter kit to empty the client's bladder (D) may be necessary if she is unable to empty her bladder on her own, but assisting her up to the bathroom should be attempted first.
Correct Answer is B
Explanation
The action by the PN that is likely to facilitate accurate responses to personal and social history questions is to **request that the mother leave the exam room**. The personal and social history contains many areas of special sensitivity to adolescents including such issues as drug and alcohol use and sexual activity. The teen should provide the personal and social history, not the parent⁴.
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