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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?

A.

Prepare for an emergency cesarean birth.

B.

Assist the client to a knee-chest position.

C.

Prepare the client for continuous internal monitoring.

D.

Continue observing the fetal heart rate.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

Rationale:

A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.

B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.

C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.

D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.

Correct Answer is D

Explanation

Rationale:

A. Decreased cholesterol is not a primary effect of chlorpromazine; the medication is primarily used for psychiatric conditions, not lipid management.

B. While chlorpromazine may have sedative effects that could impact blood pressure, decreased blood pressure is not a direct indicator of its effectiveness in treating psychiatric symptoms.

C. Decreased esophageal reflux is not a relevant effect of chlorpromazine, as it is primarily used for managing psychotic symptoms.

D. Decreased hallucinations is a direct indication of the medication's effectiveness in treating conditions such as schizophrenia or other psychotic disorders, as chlorpromazine is an antipsychotic medication.

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