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 ["A","C","D"]
Explanation
Choice a) Reason: History of migraines
Women with a history of migraines may experience an improvement or worsening of their migraine symptoms during pregnancy. Hyperemesis gravidarum, a condition characterized by severe nausea and vomiting, can be associated with migraines due to hormonal changes, stress, or dehydration that pregnancy may exacerbate.
Choice b) Reason: History of gestational hypertension
Gestational hypertension typically develops after 20 weeks of gestation, so it would not be expected in a client at 8 weeks of gestation. Additionally, there is no direct correlation between gestational hypertension and hyperemesis gravidarum.
Choice c) Reason: Twin gestations
Twin or multiple gestations can increase the likelihood of hyperemesis gravidarum due to higher levels of hCG (human chorionic gonadotropin) and other pregnancy-related hormones. These elevated hormone levels are associated with more severe nausea and vomiting.
Choice d) Reason: Nulliparous
Nulliparity (having never given birth) is not directly associated with an increased risk of hyperemesis gravidarum. However, first-time pregnancies can be unpredictable, and the condition can occur regardless of parity.
Choice e) Reason: Oligohydramnios
Oligohydramnios refers to a decreased amount of amniotic fluid and is not typically associated with hyperemesis gravidarum. It is more commonly related to conditions affecting the placenta or fetal kidneys.
Correct Answer is B
Explanation
Choice A reason:
Suctioning excess mucus with a bulb syringe is a standard procedure to clear the airways of a newborn and facilitate breathing. While it is an important aspect of initial newborn care, it does not directly prevent jaundice. Jaundice is caused by high levels of bilirubin in the blood, and suctioning mucus does not influence bilirubin levels.
Choice B reason:
Initiating early feeding, whether breastfeeding or formula feeding, is recommended to prevent jaundice. Early feeding helps stimulate bowel movements, which aids in the excretion of bilirubin through the stool. Breastfed babies should be fed eight to twelve times a day during their first week of life, and formula-fed babies should receive one to two ounces (30 to 60 milliliters) of formula every two to three hours during their first week. This frequent feeding schedule helps ensure that bilirubin does not build up to high levels in the newborn's system.
Choice C reason:
Preparing for an exchange blood transfusion is a treatment measure for severe jaundice, not a preventive action. This procedure is only considered when bilirubin levels are dangerously high and could potentially cause brain damage. It is not a standard preventive measure for jaundice in newborns.
Choice D reason:
Beginning phototherapy is a treatment method for newborns who have already developed jaundice, not a preventive measure. Phototherapy uses light to break down bilirubin in the skin, making it easier for the baby's body to eliminate it. While effective in treating jaundice, it is not used as a preventive action.