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: The rubella vaccine is a live attenuated virus vaccine, which is generally not recommended during pregnancy due to the theoretical risk to the fetus. However, it is safe to receive the rubella vaccine while breastfeeding; it does not pose a risk to the nursing infant.
Choice B reason: The varicella vaccine, which is also a live virus vaccine, should not be administered during pregnancy because of the potential risk to the fetus. Women should be vaccinated before pregnancy or in the postpartum period.
Choice C reason: The Tdap vaccine, which protects against tetanus, diphtheria, and pertussis (whooping cough), is recommended for all pregnant women during each pregnancy, regardless of their previous history of receiving the vaccine. The optimal timing for Tdap administration is between 27 and 36 weeks of gestation to maximize the transfer of antibodies to the baby.
Choice D reason: Pregnant women are encouraged to receive the inactivated influenza vaccine at any point during their pregnancy. The flu shot is safe during pregnancy and helps protect both the mother and the baby from the flu and its complications.
Correct Answer is B
Explanation
Choice A reason:
Type 1 diabetes mellitus is generally not directly associated with maternal smoking. It is an autoimmune condition where the pancreas produces little to no insulin. Risk factors for Type 1 diabetes include family history and possibly environmental factors, but maternal smoking is not a recognized risk factor.
Choice B reason:
Intrauterine growth restriction (IUGR) refers to poor growth of a fetus while in the mother's womb during pregnancy. The causes of IUGR are many, but maternal smoking is a well-documented risk factor. Smoking during pregnancy can reduce oxygen and nutrient delivery to the fetus, leading to low birth weight and other complications.
Choice C reason:
While smoking during pregnancy can increase the risk of various health issues, there is no direct and consistent evidence linking it to hearing loss in newborns. Hearing loss in newborns can be due to genetic factors, infections during pregnancy, or complications at birth.
Choice D reason:
Congenital heart defects are the most common type of birth defect, and their causes can be multifactorial, including genetic and environmental factors. Maternal smoking has been associated with an increased risk of certain congenital heart defects, but the relationship is not as strong as with intrauterine growth restriction.