While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction,
with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to:
a. Change the woman's position. c. Assist with amnioinfusion.
b. Notify the care provider. d. Insert a scalp electrode.
ANS: A
Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, the nurse would continue with subsequent intrauterine resuscitation measures, including notifying the care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely reveals variable deceleration. A fetal scalp electrode would provide accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurse's first priority.
You might also like to view...
The nurse educator is conducting an in-service to a group of new nurses regarding the use of ostomy appliances. When discussing the characteristics of ostomy appliances, which statements are appropriate for the educator to include in the presentation?
Select all that apply. 1. The ostomy appliance comes in a three-piece set. 2. The ostomy appliance should protect the skin near the stoma. 3. The ostomy appliance should collect both stool and urine. 4. The ostomy appliance controls odor. 5. All ostomy appliances can only be used once.
A nursing student is learning the difference between theoretical and conceptual frameworks. Which statement, if made by the student, indicates the need for further teaching?
1. A theoretical framework presents a broad, general explanation of the relationships between the concepts of interest in a research study. 2. A conceptual framework helps to explain the relationship between concepts. 3. A conceptual framework is a less well-developed structure than a theoretical framework but may serve as the impetus for the formulation of a theory. 4. A theoretical framework is based on many existing theories.
A patient has been admitted to the neurological unit from the PACU after successful neurosurgery to remove a brain tumor. The nurse's admitting assessment reveals that the patient's gag reflex has not yet fully returned
The nurse should recognize that this assessment finding has the potential to cause which of the following nursing diagnoses? A) Risk for aspiration B) Impaired spontaneous ventilation C) Dysfunctional ventilator weaning response D) Imbalanced nutrition: less than body requirements
While participating in a group therapy session, one group member consistently asks for clarification of the topic the group is discussing. The nurse leading the group interprets this behavior as reflecting which group role?
A) Coordinator B) Recorder C) Information seeker D) Standard setter