A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?
Prepare for an emergency cesarean birth.
Assist the client to a knee-chest position.
Prepare the client for continuous internal monitoring.
Continue observing the fetal heart rate.
The Correct Answer is D
Rationale:
A. Early decelerations are typically benign and often associated with head compression, not necessitating an emergency cesarean birth.
B. A knee-chest position is generally used for variable decelerations but is not indicated for early decelerations.
C. Continuous internal monitoring may be necessary in certain situations, but in the case of early decelerations, it is not an immediate intervention.
D. Early decelerations usually require continued monitoring without immediate intervention as they typically resolve spontaneously with contractions.
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Correct Answer is B
Explanation
Rationale:
A. Arterial blood gases (ABGs) are typically used to assess respiratory function and acid-base balance, which are not primary concerns with valproic acid use.
B. Serum liver enzyme levels are critical to monitor due to the risk of hepatotoxicity associated with valproic acid therapy, making this test essential for safe management.
C. A chest X-ray is generally used to assess respiratory conditions, not relevant for monitoring the effects of valproic acid.
D. Urine culture and sensitivity are used to diagnose urinary tract infections and are not relevant to the monitoring of valproic acid therapy.
Correct Answer is D
Explanation
Rationale:
A. Speaking loudly in a high-pitched voice is not effective for individuals with sensorineural hearing loss, as they may struggle with high-frequency sounds.
B. Asking the client's partner to choose their meal removes the client's autonomy and does not facilitate direct communication.
C. While expecting extended time for verbal responses is considerate, it does not provide a practical solution for meal selection.
D. Asking the client to point to items on a picture menu is an effective way to facilitate communication, allowing the client to express their preferences without relying on verbal communication alone.