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 D
Explanation
Rationale:
A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia.
B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase.
C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase.
D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.
Correct Answer is A
Explanation
Rationale
A. Contact precautions are appropriate for MRSA to prevent the transmission of bacteria through direct or indirect contact with the infected area. This includes wearing gloves and gowns when caring for the client and ensuring proper hand hygiene.
B. Droplet precautions are used for pathogens that are spread through respiratory droplets, which is not applicable to MRSA.
C. Protective equipment is typically used for immunocompromised patients to prevent infections, but it is not the standard for MRSA.
D. Airborne precautions are necessary for diseases that spread through airborne particles, which does not include MRSA.