The nurse is caring for a client at 39 weeks gestation in active labor. The client had a spontaneous rupture of membranes 2 hours ago with clear amniotic fluid noted. The client was 7 cm at the time of SROM. The nurse assesses the fetal heart rate monitor and identifies a fetal heart baseline of 145 bpm, with moderate variability, accelerations absent and recurrent variable decelerations.
Which of the following interventions should the nurse take? Select all that apply.
Notify the provider.
Encourage the client to ambulate in the hallway.
Reposition the patient to the left lateral position.
Perform a sterile vaginal exam.
Correct Answer : A,C,D,E
Choice A rationale
Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to
monitor labor progression.
Choice B rationale
Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.
Choice C rationale
Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.
Choice D rationale
Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.
Choice E rationale
Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord
compression effects. .
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Correct Answer is B
Explanation
Choice A rationale
Copious vernix is typically found on preterm newborns, not those born post-term.
Choice B rationale
Dry, cracked skin is a common finding in post-term newborns due to prolonged exposure to amniotic fluid.
Choice C rationale
Decreased subcutaneous fat is more likely in preterm newborns, while post-term newborns might lose some fat due to nutrient depletion.
Choice D rationale
Scant scalp hair is more common in preterm infants, whereas post-term infants usually have more developed hair. .
Correct Answer is D
Explanation
Choice A rationale
Phototherapy is a treatment for jaundice but is not a preventive measure. It is used after jaundice has been identified to reduce bilirubin levels in the newborn.
Choice B rationale
Suctioning excess mucus with a bulb syringe helps clear the newborn’s airways but does not have a direct role in preventing jaundice. Jaundice is related to bilirubin metabolism, not
mucus accumulation.
Choice C rationale
Preparing for an exchange blood transfusion is an intervention for severe hyperbilirubinemia but is not a preventive measure for jaundice. It is used when bilirubin levels are
extremely high.
Choice D rationale
Initiating early feeding helps to promote bowel movements, which assists in the excretion of bilirubin from the body. This is an effective preventive measure for jaundice, as it helps
reduce the chances of bilirubin buildup.