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This is incorrect. Increasing the infusion rate of the IV fluid is not the first action the nurse should take. IV fluid can help increase the blood volume and improve the placental perfusion, but it is not the most effective way to relieve the uteroplacental insufficiency that causes late decelerations. It may also cause fluid overload or edema in the mother or the fetus.

This is incorrect. Administering oxygen via face mask is not the first action the nurse should take. Oxygen can increase the oxygen saturation and the partial pressure of oxygen in the maternal blood, which can benefit the fetus. However, it is not the most immediate way to address the cause of late decelerations, which is the reduced blood flow to the placenta. It may also have adverse effects, such as hyperoxia or oxidative stress.

This is incorrect. Elevating the client's legs is not the first action the nurse should take. Elevating the legs can help increase the venous return and the cardiac output, which can improve the maternal and fetal hemodynamics. However, it is not the most urgent way to resolve the problem of late decelerations, which is the impaired placental function. It may also worsen the compression of the major vessels by the uterus, which can decrease the blood flow to the placenta.

This is incorrect. Covering the cord with a sterile, moist saline dressing is not the first action the nurse should take. This can help prevent the cord from drying out and becoming infected, but it does not address the main issue, which is the compression of the cord by the fetal head or the uterine wall. This can compromise the fetal oxygenation and circulation, leading to fetal distress or death.

This is incorrect. Explaining to the client what is happening is not the first action the nurse should take. This can help calm the client and gain their cooperation, but it does not deal with the immediate danger, which is the loss of fetal oxygen and nutrients due to the cord prolapse. The nurse should prioritize the interventions that can save the fetal life.

This is incorrect. Preparing the client for an emergency cesarean birth is not the first action the nurse should take. This is the definitive treatment for cord prolapse, as it can deliver the fetus as quickly as possible and prevent further complications. However, it is not the most rapid way to manage the situation, as it requires time to prepare the operating room, the anesthesia, and the surgical team. The nurse should first implement the measures that can maintain the fetal well-being until the surgery.

This is incorrect. Covering the cord with a sterile, moist saline dressing is not the first action the nurse should take. This can help prevent the cord from drying out and becoming infected, but it does not address the main issue, which is the compression of the cord by the fetal head or the uterine wall. This can compromise the fetal oxygenation and circulation, leading to fetal distress or death.

This is incorrect. Explaining to the client what is happening is not the first action the nurse should take. This can help calm the client and gain their cooperation, but it does not deal with the immediate danger, which is the loss of fetal oxygen and nutrients due to the cord prolapse. The nurse should prioritize the interventions that can save the fetal life.

This is incorrect. Preparing the client for an emergency cesarean birth is not the first action the nurse should take. This is the definitive treatment for cord prolapse, as it can deliver the fetus as quickly as possible and prevent further complications. However, it is not the most rapid way to manage the situation, as it requires time to prepare the operating room, the anesthesia, and the surgical team. The nurse should first implement the measures that can maintain the fetal well-being until the surgery.

This is incorrect. Informing the client that she can go to the bathroom whenever needed is not the best action the nurse should take. The client may have a decreased sensation of bladder fullness or a weak bladder tone after a vaginal birth, which can lead to urinary retention or overflow incontinence. The nurse should encourage the client to void within 4 to 6 hours after delivery and monitor the urine output and characteristics.

This is incorrect. Advising the client to remain in bed for the next few hours is not the best action the nurse should take. The client may benefit from early ambulation after a vaginal birth, as it can promote circulation, prevent thrombosis, and enhance bowel and bladder function. The nurse should assist the client to get out of bed safely and gradually, and observe for signs of orthostatic hypotension or bleeding.

This is incorrect. Evaluating the side effects of any analgesics used during labor is not the best action the nurse should take. The client may have received analgesics, such as opioids or epidural, during labor, which can cause side effects, such as nausea, vomiting, itching, or respiratory depression. The nurse should monitor theclient for these effects and provide appropriate interventions, but this is not the priority action after a vaginal birth.

This is incorrect. Dinoprostone does not increase the frequency of contractions. Dinoprostone may cause mild contractions, but it is not intended to induce labor. It is used to prepare the cervix for labor, not to start it. Other medications, such as oxytocin, are used to stimulate uterine contractions.

This is incorrect. Dinoprostone does not decrease the risk of infection. Dinoprostone may increase the risk of infection, especially if the membranes are ruptured or the gel is left in the vagina for too long. The nurse should monitor the client for signs of infection, such as fever, chills, or foul-smelling discharge.

This is incorrect. Dinoprostone does not reduce the pain of labor. Dinoprostone may cause cramping, backache, or pelvic pain, which can be similar to labor pain. The nurse should provide comfort measures and analgesics as needed¹.

This is incorrect. Urinary output is not the best indicator of the effectiveness of oxytocin. Urinary output may be affected by various factors, such as fluid intake, fluid loss, bladder tone, or kidney function. The nurse should monitor the urinary output to prevent urinary retention or infection, but it does not reflect the action of oxytocin².

This is incorrect. Pulse rate is not the best indicator of the effectiveness of oxytocin. Pulse rate may be influenced by various factors, such as pain, anxiety, blood loss, or dehydration. The nurse should monitor the pulse rate to assess the hemodynamic status of the client, but it does not reflect the action of oxytocin².

This is incorrect. Blood pressure is not the best indicator of the effectiveness of oxytocin. Blood pressure may be affected by various factors, such as pain, anxiety, blood loss, or dehydration. The nurse should monitor the blood pressure to assess the hemodynamic status of the client, but it does not reflect the action of oxytocin².

This is incorrect. Three fingerbreadths above the umbilicus is not the expected position of the uterine fundus 12 hr postpartum. The uterine fundus is the upper part of the uterus that can be palpated through the abdomen. Immediately after delivery, the fundus is at the level of the umbilicus or slightly below. It then descends about one fingerbreadth per day until it reaches the pelvic cavity by the tenth day. If the fundus is higher than expected, it may indicate uterine atony, distended bladder, or retained placenta.

This is incorrect. One fingerbreadth above the symphysis pubis is not the expected position of the uterine fundus 12 hr postpartum. The symphysis pubis is the joint where the two halves of the pelvis meet in the front. The fundus is normally at this level by the tenth day postpartum, not the first day. If the fundus is lower than expected, it may indicate uterine inversion, subinvolution, or infection.

This is incorrect. To the right of the umbilicus is not the expected position of the uterine fundus 12 hr postpartum. The fundus should be midline and symmetrical, not deviated to either side. If the fundus is displaced to the right, it may indicate a full bladder, which can interfere with the uterine contraction and involution. The nurse should encourage the client to void and reassess the fundal position.

This is incorrect. Four contractions in a 10-min period is not a finding that the nurse should report to the provider. This is a normal frequency of contractions during the active phase of labor, which occurs when the cervix is dilated from 4 to 7 cm. The nurse should monitor the contractions and the fetal heart rate, but there is no need to alert the provider unless there are signs of complications.

This is incorrect. Contraction resting period 35 seconds is not a finding that the nurse should report to the provider. This is a normal duration of the interval between contractions during the active phase of labor, which allows the uterus and the placenta to relax and replenish the blood and oxygen supply to the fetus. The nurse should monitor the contractions and the fetal heart rate, but there is no need to alert the provider unless there are signs of complications.

This is incorrect. Contraction lasting 85 seconds is not a finding that the nurse should report to the provider. This is a normal duration of contractions during the active phase of labor, which helps the cervix to efface and dilate. The nurse should monitor the contractions and the fetal heart rate, but there is no need to alert the provider unless there are signs of complications.

This is incorrect. Initiating an IV infusion of magnesium sulfate is not the appropriate action for a client who has heavy vaginal bleeding. Magnesium sulfate is a medication that is used to prevent seizures in clients who have preeclampsia or eclampsia, which are conditions that cause high blood pressure and proteinuria during pregnancy. It does not stop bleeding or improve the condition of the placenta or the fetus.

This is incorrect. Administering antibiotics is not the appropriate action for a client who has heavy vaginal bleeding. Antibiotics are medications that are used to treat or prevent infections caused by bacteria. They do not stop bleeding or improve the condition of the placenta or the fetus.

This is incorrect. Requesting the RN perform a cervical examination is not the appropriate action for a client who has heavy vaginal bleeding. A cervical examination is a procedure that involves inserting a gloved finger into the vagina to check the dilation and effacement of the cervix. It can cause more bleeding or damage the placenta or the fetus, especially if the client has placenta previa, which is a condition where the placenta covers the opening of the cervix.

This is incorrect. Increasing IV fluids is not the appropriate action for a nurse who notes that the fundus is slightly deviated to the right. IV fluids can help maintain hydration and blood volume, but they do not address the cause of the fundal deviation, which is a full bladder. Excessive IV fluids may also cause fluid overload or edema in the mother or the baby.

This is incorrect. Encouraging the client to nurse more frequently is not the appropriate action for a nurse who notes that the fundus is slightly deviated to the right. Nursing can stimulate the release of oxytocin, which is a hormone that helps the uterus contract and prevent bleeding. However, it does not address the cause of the fundal deviation, which is a full bladder. Nursing may also be uncomfortable or difficult for the client if her bladder is distended.

This is incorrect. Reporting the client's temperature is not the appropriate action for a nurse who notes that the fundus is slightly deviated to the right. The client's temperature is within the normal range for a postpartum client, as it may be slightly elevated due to dehydration, exertion, or breast engorgement. It does not indicate an infection or a complication that needs to be reported. It also does not address the cause of the fundal deviation, which is a full bladder.