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 B
Explanation
Choice A reason:
Notifying the provider of the findings is important, but it is not the immediate priority. The provider should be informed after initial measures to stabilize the client's condition have been taken.
Choice B reason:
Positioning the client with one hip elevated, also known as the lateral or left-lateral position, is the priority action. This position can help improve blood flow and potentially increase the maternal blood pressure, which is critically low at 92/54 mm Hg. It also helps to optimize uteroplacental perfusion, which is essential for the well-being of both the mother and the fetus.
Choice C reason:
Having the client void can be helpful in preventing bladder distention, which can interfere with labor progress. However, it is not the priority action when the client's blood pressure is significantly low.
Choice D reason:
Asking the client if she needs pain medication is an important part of comfort care during labor. However, addressing the client's low blood pressure is a more immediate concern to prevent potential complications for both the mother and the fetus.
Correct Answer is C
Explanation
Choice a reason:
Placing the client in the Trendelenburg position, which involves lying on the back with the feet higher than the head, is not indicated for the symptoms presented. This position is typically used to treat hypotension or improve venous return to the heart, not for respiratory depression or absent deep-tendon reflexes, which are signs of magnesium sulfate toxicity.
Choice b reason:
Assessing maternal blood glucose is important in the overall care of a preeclamptic patient, especially if there is a concern for gestational diabetes. However, it is not the immediate action required when a patient exhibits signs of magnesium sulfate toxicity, such as a respiratory rate of 10/min and absent deep-tendon reflexes.
Choice c reason:
Discontinuing the medication infusion is the correct action. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Immediate cessation of the drug is necessary to prevent further complications, such as respiratory depression or cardiac arrest. After stopping the infusion, the nurse should monitor the patient closely and prepare to administer calcium gluconate, the antidote for magnesium sulfate toxicity, if ordered by the physician.
Choice d reason:
Preparing for an emergency cesarean birth may be necessary if the fetus is in distress or if there are other obstetric indications. However, the information provided does not indicate fetal distress or an immediate need for delivery. The priority is addressing the signs of magnesium sulfate toxicity in the mother.