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 A
Explanation
Choice A reason:
After a vaginal delivery, the uterus begins to contract and shrink back to its pre-pregnancy size, a process known as involution. Immediately after delivery, the fundus is typically at the level of the umbilicus. Within 12 hours postpartum, the fundus is expected to rise to approximately 1 cm above the umbilicus. Therefore, finding the fundus 2 cm above the umbilicus may indicate that the uterus is not contracting as expected, which could be a sign of uterine atony, a condition that can lead to postpartum hemorrhage.
Choice B reason:
Normally, the fundus is at the level of the umbilicus immediately after delivery and then rises slightly before beginning to descend. If the fundus is found at the level of the umbilicus 12 hours postpartum, it could suggest that the uterus is contracting appropriately and involution is proceeding normally.
Choice C reason:
One fingerbreadth above the symphysis pubis is significantly lower than the expected position of the fundus at 12 hours postpartum. This position would be more consistent with the location of the fundus several days after delivery, as the uterus continues to contract and descend at a rate of about 1 cm per day until it is no longer palpable above the symphysis pubis.
Choice D reason:
The fundus should be midline in the abdomen. If the fundus is palpated to the right of the umbilicus, it may indicate that the bladder is full and displacing the uterus, or it could be a sign of uterine atony or other complications. It is important for the nurse to assess for bladder distention and ensure that the client is voiding regularly postpartum.
Correct Answer is C
Explanation
Choice a reason:
The viability of the fetus at 38 weeks of gestation is typically not the primary concern when heavy, red vaginal bleeding occurs without contractions. Fetal movements reported by the mother are a good sign of fetal well-being. However, the ultrasound in this scenario is more likely to be used to rule out placental issues that could cause bleeding, rather than to assess fetal viability.
Choice b reason:
The biparietal diameter (BPD) is a measurement taken during an ultrasound to assess fetal growth and development. While BPD is an important parameter, it is not typically the focus of an urgent ultrasound in the context of heavy vaginal bleeding late in pregnancy. The BPD is more relevant to growth assessments rather than acute bleeding episodes.
Choice c reason:
Locating the placenta is crucial in the case of heavy, red vaginal bleeding at 38 weeks of gestation. The bleeding could be indicative of placental abruption or placenta previa, both of which are serious conditions that require immediate medical attention. An ultrasound can quickly determine the location of the placenta and assess for these conditions.
Choice d reason:
Assessing fetal lung maturity is not typically the priority in an emergency situation involving heavy vaginal bleeding. While lung maturity is an important consideration for the timing of delivery, especially in preterm labor, the immediate concern in this scenario would be to identify the source of bleeding and ensure the safety of both the mother and fetus.