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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice a reason:
Limiting alcohol consumption is important during pregnancy to prevent fetal alcohol syndrome and other developmental issues, but it is not specifically related to the prevention of neural tube defects. Alcohol can interfere with the body's ability to absorb certain nutrients, but folic acid intake is the key factor in preventing neural tube defects.
Choice b reason:
Avoiding foods containing aspartame is often recommended for overall health, but there is no direct link between aspartame and neural tube defects. Aspartame is an artificial sweetener found in many diet foods and beverages, and while some people choose to avoid it for various health reasons, it is not specifically associated with neural tube defects.
Choice c reason:
Increasing the intake of iron-rich foods is crucial for preventing anemia during pregnancy and ensuring the baby has enough iron stores. However, iron does not play a direct role in the prevention of neural tube defects. Neural tube defects are related to folic acid, not iron.
Choice d reason:
Consuming foods fortified with folic acid is the most critical factor in preventing neural tube defects. Folic acid is a B vitamin that is essential for the proper development of the neural tube, which becomes the baby's brain and spinal cord. Adequate folic acid intake before conception and during early pregnancy can significantly reduce the risk of neural tube defects.
Correct Answer is B
Explanation
Choice A reason:
The deltoid muscle, while commonly used for IM injections in older children and adults, is not the preferred site for newborns due to their underdeveloped muscle mass in this area. Administering an injection in the deltoid could increase the risk of injury to the surrounding nerves and tissues in newborns.
Choice B reason:
The vastus lateralis muscle is the recommended site for IM injections in newborns. It is the preferred location because it is the largest muscle in the thigh and has sufficient mass to absorb the medication effectively. This muscle is located on the anterolateral aspect of the thigh and is considered the safest site with the least risk of damaging blood vessels, nerves, or bone.
Choice C reason:
The dorsogluteal muscle, located in the buttocks, was once a common site for IM injections. However, it is no longer recommended due to the high risk of injury to the sciatic nerve and significant blood vessels in the area. Additionally, the fat content in the buttocks can affect the absorption of the medication.
Choice D reason:
The ventrogluteal muscle, also located in the hip area, is another site for IM injections but is more suitable for older children and adults. For newborns, the vastus lateralis remains the preferred site due to easier access and less risk of complications.