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:
A soft, edematous area on the scalp, often referred to as a cephalohematoma, is a common finding after vacuum-assisted deliveries. This is due to the suction applied during delivery and usually resolves without intervention. However, it should be monitored for any signs of increased swelling or jaundice as it can sometimes lead to hyperbilirubinemia.
Choice B reason:
The blue coloring of the hands and feet, known as acrocyanosis, is a normal finding in the first few days of life. It occurs due to the immature circulation in the newborn and typically resolves as the baby's circulation adapts to life outside the womb.
Choice C reason:
Facial edema can be present in newborns following a vacuum-assisted delivery due to the pressure applied during the procedure. It is usually transient and resolves within a few days. However, persistent or severe edema may warrant further evaluation.
Choice D reason:
Poor sucking is a significant finding that should be reported to the provider. Effective sucking is crucial for adequate nutrition and hydration in the newborn. Poor sucking can be a sign of neurological compromise or other issues that require immediate attention to ensure the baby can feed properly and thrive.
Correct Answer is D
Explanation
Choice A reason:
Urinary frequency typically begins early in pregnancy due to hormonal changes and increased blood volume leading to more fluid being processed by the kidneys and ending up in the bladder. While it often improves in the second trimester as the uterus rises into the abdominal cavity, poor bladder tone is not typically cited as a reason for its continuation.
Choice B reason:
While urinary frequency can be seen as a minor inconvenience, it should not be ignored. It is a normal physiological change during pregnancy. However, if it is accompanied by pain, burning, or any other symptoms, it could indicate a urinary tract infection, which requires medical attention.
Choice C reason:
There is some predictability to urinary frequency in pregnancy. It often starts in the first trimester, improves in the second, and may return in the third trimester as the growing baby and uterus exert pressure on the bladder.
Choice D reason:
This choice is accurate. Urinary frequency is common in the first trimester due to hormonal changes and the growing uterus pressing on the bladder. It often returns in the third trimester when the baby "drops" and the head presses on the bladder. This is a normal part of pregnancy and usually does not indicate any complications.