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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Related Questions
Correct Answer is D
Explanation
To best help develop interventions for a toddler with failure to thrive due to inadequate caloric intake, the practical nurse (PN) should monitor parent-toddler interaction. Observing how the parent and toddler interact during mealtimes can provide valuable information about the child's eating habits and any potential issues that may be contributing to the inadequate caloric intake. The PN can use this information to develop interventions that address any identified issues and promote healthy eating habits. The other observations listed may also be important to monitor, but observing parent-toddler interaction is the most useful in this situation.
Correct Answer is A
Explanation
This can offer a safe place for her and her unborn child. The shelter can also provide resources for counseling and legal assistance if needed.
The safety plan and restraining order are important measures, but the priority should be to ensure the client's immediate safety.
The visit summary documenting the report of abuse is also important, but it should not be the only information provided to the client.
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