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?
Elevate the client's legs.
Turn the client onto their side.
Palpate the client's uterus.
Increase the client's IV fluid infusion rate.
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
- 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 D
Explanation
Choice A rationale
Bumper pads can pose a suffocation risk to the newborn. The American Academy of Pediatrics advises against their use to promote a safe sleep environment.
Choice B rationale
Foam-wedge cushions are not recommended as they can increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS) by obstructing airflow.
Choice C rationale
Plastic covers can pose a suffocation hazard. Instead, using a fitted sheet is safer and reduces the risk of suffocation.
Choice D rationale
A well-fitting mattress reduces gaps between the mattress and crib sides, preventing entrapment, which helps reduce the risk of suffocation and injury.
Correct Answer is C
Explanation
Choice A rationale
Auscultating fetal heart tones during a contraction does not provide a clear assessment of the fetal heart rate pattern and can be affected by the contraction itself.
Choice B rationale
Placing a Doppler ultrasound over the fundus is not effective, as the fundus is not the optimal location to hear fetal heart tones, especially in early labor.
Choice C rationale
Performing Leopold maneuvers to determine fetal position is crucial as it helps in placing the Doppler in the correct position for accurate monitoring of fetal heart tones.
Choice D rationale
Counting the fetal heart rate for 15 seconds and then multiplying by 4 may not provide an accurate assessment of the fetal heart rate pattern or variability, which is important for fetal well-being assessment. .