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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.

A.

Notify the provider.

B.

Encourage the client to ambulate in the hallway.

C.

Reposition the patient to the left lateral position.

D.

Perform a sterile vaginal exam.

Question Solution

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.

Choice B rationale

Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.

Choice C rationale

Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.

Choice D rationale

Age less than 25 years is not a risk factor for breast cancer; risk increases with age.

Correct Answer is ["A","B","C","D","G"]

Explanation

Choice A: Respiratory assessment

The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.

Choice B: Hemoglobin

The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.

Choice C: Serum glucose

The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.

Choice D: Heart rate

The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.

Choice G: Hematocrit

The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2

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