While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate during the contraction's peak, with the nadir of the decelerations occurring when the contraction end. The nurse's first priority is to:
Select one:
Insert a scalp electrode.
Notify the care provider.
Assist with amnioinfusion.
Reposition the patient.
The Correct Answer is D
a. A scalp electrode is not indicated unless there is a problem with the external monitor tracing or if further assessment of the fetal heart rate variability is needed.
b. This is important but repositioning the patient is the priority.
c. Amnioinfusion is only done if repositioning the patient does not resolve the late decelerations.
d. The nurse is observing late decelerations of the fetal heart rate, which indicate uteroplacental insufficiency and fetal hypoxia. The nurse's first priority is to reposition the patient to improve placental blood flow and oxygen delivery to the fetus. Repositioning can be done by turning the patient to her side, elevating her legs, or placing a wedge under her hip.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. This is a test for renal function, not fetal lung maturity.
b. This is a test for glucose control, not fetal lung maturity.
c. An L/S ratio of 2:1 or greater indicates that the fetal lungs have reached maturity.
d. This is a test of fetal well-being and does not indicate fetal lung maturity. This ratio indicates that the fetal lungs have enough surfactant to prevent alveolar collapse and respiratory distress syndrome.
Correct Answer is C
Explanation
a. This may be necessary once the woman's condition stabilizes, but it is not the initial treatment.
b. This is not typically indicated for hyperemesis gravidarum.
c. This is the initial treatment for hyperemesis gravidarum to prevent dehydration and correct electrolyte imbalances.
d. This may be part of the treatment plan, but it is not the initial treatment.
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