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.
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Correct Answer is A
Explanation
Choice A rationale
Each feeding should last between 20 and 30 minutes to ensure the baby gets enough nutrition and to facilitate bonding time.
Choice B rationale
Prepared formula should be used within 24 hours if stored in the refrigerator, not 5 days, to prevent bacterial growth and ensure the baby's safety.
Choice C rationale
Formula left at room temperature should not be refrigerated for reuse; it can develop bacteria that may harm the baby.
Choice D rationale
It is recommended to burp the baby multiple times during feeding to release swallowed air and prevent discomfort or spitting up.
Correct Answer is B
Explanation
Choice A rationale
A client whose labor lasted for 6 hours is not necessarily a priority unless other complications are present. Duration of labor alone does not indicate an urgent need for immediate attention postpartum.
Choice B rationale
A client who received magnesium sulfate during labor should be seen first due to the potential for serious side effects such as respiratory depression, hypotonia in the newborn, and maternal complications. Magnesium sulfate is used to prevent seizures in clients with preeclampsia and requires close monitoring.
Choice C rationale
A client with a history of oligohydramnios needs monitoring, but this condition alone does not take precedence over the immediate postpartum risks associated with magnesium sulfate.
Choice D rationale
A client whose newborn is having difficulty latching-on needs support and assistance with breastfeeding. While important, this issue is not as urgent as monitoring the effects of magnesium sulfate in the client described in Choice B.