Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

A nurse is assisting with the care of a client who is in active labor.

The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A.

Elevate the client's legs.

B.

Turn the client onto their side.

C.

Palpate the client's uterus.

D.

Increase the client's IV fluid infusion rate.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.

 

Choice B rationale

 

Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.

 

Choice C rationale

 

Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.

 

Choice D rationale

 

Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is B

Explanation

Choice A rationale

Ensuring the client has a full bladder before the procedure is incorrect. A full bladder can cause discomfort during the pelvic examination and may obscure the pelvic organs, making the examination more challenging for the provider.

Choice B rationale

Instructing the client to bear down when the speculum is inserted is correct. Bearing down helps relax the pelvic muscles, making it easier to insert the speculum and perform the examination with minimal discomfort.

Choice C rationale

Encouraging the client to take rapid, shallow breaths during the procedure is incorrect. This can increase anxiety and tension in the pelvic muscles, making the examination more uncomfortable.

Choice D rationale

Applying povidone-iodine to the provider's fingers prior to bimanual examination is incorrect. The standard procedure involves using gloves and lubricant to prevent infection and ensure patient comfort, not povidone-iodine.

Correct Answer is A

Explanation

Choice A rationale

"You will be tested again for GBS at about 36 weeks of gestation.”. This is correct because retesting for GBS at 35-37 weeks of gestation is standard practice to identify colonization status before delivery, which helps in planning intrapartum antibiotic prophylaxis.

Choice B rationale

"If you test positive for GBS, the provider will need to perform a cesarean birth.”. This is incorrect because GBS colonization is not an indication for cesarean delivery. The primary intervention is antibiotic administration during labor to prevent neonatal infection.

Choice C rationale

"You will take an antibiotic during the last 2 weeks of pregnancy to avoid transferring GBS to your baby.”. This is incorrect because antibiotics are given intrapartum (during labor) to prevent GBS transmission, not during the last weeks of pregnancy.

Choice D rationale

"This infection can cause your baby to experience hearing loss at birth.”. This is incorrect because GBS infection primarily causes sepsis, pneumonia, and meningitis in neonates, not hearing loss.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2025, All Right Reserved.