A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse notices that the fetal heart rate starts to decrease after a contraction begins, with the lowest rate occurring after the contraction's peak. What should be the nurse's first action?
Administer oxygen using a non-rebreather mask.
Increase the rate of maintenance IV infusion.
Elevate the client's legs.
Place the client in the lateral position.
The Correct Answer is D
Choice A reason:
Administering oxygen using a non-rebreather mask is a subsequent step if initial measures do not improve fetal heart rate decelerations. It can help increase the amount of oxygen available to the fetus. Oxygen administration is a supportive measure that can be used if there are signs of fetal distress. In the scenario described, where the fetal heart rate slows after the start of a contraction with the lowest rate occurring after the peak, it suggests late decelerations, which are often associated with uteroplacental insufficiency. Administering oxygen can help increase the fetal oxygen reserve and is a common intervention during labor when there are concerns about fetal well-being.
Choice B reason:
Increasing the rate of maintenance IV infusion is typically considered when there is a concern for maternal hypotension or dehydration, which may not be the immediate cause of the observed fetal heart rate pattern. Increasing the rate of an IV infusion can help improve maternal hydration and blood pressure, which in turn can enhance placental perfusion. However, this intervention is more indirect and may not provide the immediate response needed to address fetal heart rate decelerations. It is typically considered after more direct interventions, such as repositioning the mother, have been attempted.
Choice C reason:
Elevating the client's legs can help improve venous return to the heart, potentially increasing maternal cardiac output and blood flow to the placenta. While this can be beneficial, it is not the primary intervention for late decelerations. Repositioning the mother to improve uteroplacental circulation is generally the first step.
Choice D reason:
Placing the client in the lateral position is often the first action taken when late decelerations are observed. This position helps improve uteroplacental blood flow and can quickly address potential issues related to fetal oxygenation. This position helps to relieve pressure on the inferior vena cava and aorta, which can be compressed by the gravid uterus, especially in the supine position. Relieving this pressure helps to improve uteroplacental circulation and can quickly address the cause of late decelerations, which is often related to compromised blood flow to the placenta.
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View Related questions
Correct Answer is D
Explanation
Choice a reason:
Monitoring the heart rate is important for any newborn, but it is not the priority intervention for an SGA newborn. SGA newborns are at risk for several complications, but abnormal heart rates are not a primary concern directly related to being small for gestational age.
Choice b reason:
While monitoring weight is a part of routine newborn care and important for tracking growth and development, it is not the most immediate concern for an SGA newborn. The priority is to address potential acute complications that can arise from being small for gestational age.
Choice c reason:
Monitoring axillary temperature is important for maintaining normothermia in newborns, especially those who are SGA, as they have less subcutaneous fat and are more prone to heat loss. However, the most critical and immediate risk for SGA newborns is hypoglycemia, making blood glucose monitoring a higher priority.
Choice d reason:
SGA newborns are at increased risk for hypoglycemia due to their decreased glycogen stores. Therefore, monitoring blood glucose levels is a priority intervention. Hypoglycemia can lead to serious complications such as seizures and brain injury if not promptly identified and treated. It is essential to monitor blood glucose levels frequently and intervene as necessary to maintain them within a normal range.
Correct Answer is C
Explanation
Choice a reason:
While there is always a risk of introducing infection with an internal examination, this is not the primary concern with placenta previa. Infections are a risk with any invasive procedure, but the precautions taken during a typical internal examination minimize this risk.
Choice b reason:
Initiating preterm labor is a concern with any manipulation of the cervix or uterus during pregnancy. However, at 37 weeks, the pregnancy is considered early-term, and the risk of preterm labor is not the primary concern in the context of placenta previa.
Choice c reason:
The primary reason for avoiding an internal examination in a client with placenta previa is the risk of profound bleeding. With placenta previa, the placenta covers part or all of the cervix. An internal examination could disturb the placenta and lead to significant hemorrhage, which can be life-threatening for both the mother and the fetus.
Choice d reason:
While there is a risk of rupturing the membranes during an internal examination, this is not the primary concern with placenta previa. The main issue is the potential for causing significant bleeding due to the placenta's location over the cervix.
