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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View Related questions
Correct Answer is B
Explanation
Choice A rationale
Bleeding gums can be common during pregnancy due to increased blood flow and hormonal changes that affect the gums, causing them to be more sensitive and prone to bleeding. It's usually not a cause for immediate concern unless it's severe or accompanied by other symptoms.
Choice B rationale
Abdominal cramping at 26 weeks of gestation could indicate preterm labor or other complications, such as placental abruption. It's a significant symptom that needs immediate medical attention to ensure both maternal and fetal well-being.
Choice C rationale
White vaginal discharge, known as leukorrhea, is common during pregnancy due to increased production of estrogen and greater blood flow to the vaginal area. It helps prevent infections and usually does not indicate a problem unless it has a foul odor or is accompanied by itching or irritation.
Choice D rationale
Asymptomatic palpitations are relatively common during pregnancy due to increased blood volume and changes in circulation. They usually don't indicate a serious problem unless they're severe, persistent, or accompanied by other symptoms like chest pain or shortness of breath.
Correct Answer is A
Explanation
Choice A rationale
A single crease in the palm, known as a simian crease, is a common characteristic seen in infants with trisomy 21 (Down syndrome) due to the unique hand structure associated with this condition.
Choice B rationale
A notch in the lip, such as a cleft lip, is not commonly associated with trisomy 21 and is more typically related to other genetic conditions or environmental factors during development.
Choice C rationale
An inversion of the foot, such as clubfoot, is not a specific characteristic of trisomy 21. This condition is more often seen in other congenital anomalies not related to Down syndrome.
Choice D rationale
Extra digits on the hand, or polydactyly, is not commonly associated with trisomy 21 but can be seen in other genetic disorders. Trisomy 21 has more specific physical features like the simian crease.