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
Explanation
Choice A reason: When a client in active labor presents with hypotension, as indicated by a blood pressure reading of 82/52 mm Hg, the priority nursing intervention is to assist the client to turn onto her side. This position helps to alleviate pressure on the inferior vena cava, which can be compressed by the gravid uterus, thereby improving venous return and increasing blood pressure. It also enhances uteroplacental perfusion, providing better oxygenation to the fetus.
Choice B reason: While preparation for a cesarean birth may be necessary if there are signs of fetal distress or if the hypotension does not resolve, it is not the first-line intervention for isolated hypotension without other indications.
Choice C reason: Preparing for an immediate vaginal delivery is not the priority action in response to hypotension. The focus should be on stabilizing the mother's blood pressure to ensure safe delivery, whether vaginal or cesarean.
Choice D reason: Assisting the client to an upright position is not advisable in the case of hypotension, as this can further decrease venous return to the heart and exacerbate the low blood pressure.
Correct Answer is C
Explanation
Choice a reason:
Increased subcutaneous fat is generally associated with a well-nourished newborn and is not specifically indicative of postmaturity. Newborns who are post-term may have an average or even decreased amount of subcutaneous fat due to the depletion of fat stores as the placenta ages and becomes less efficient at delivering nutrients.
Choice b reason:
Scant scalp hair is not a typical finding in a post-term newborn. In fact, post-term newborns often have abundant hair due to their longer gestational period, which allows more time for hair growth.
Choice c reason:
Dry, cracked skin is a common finding in post-term newborns. As the pregnancy extends beyond the expected term, the protective vernix caseosa that coats the skin in utero is absorbed, leaving the skin exposed to the amniotic fluid for a prolonged period. This can result in the skin becoming dry and cracked.
Choice d reason:
Copious vernix is not expected in a post-term newborn. Vernix caseosa, the white, cheese-like substance that covers the skin of the fetus, is typically present in larger amounts in pre-term newborns. By 42.5 weeks of gestation, most of the vernix has been shed into the amniotic fluid.