The laboring patient has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100–105. Which nursing action is most important?
1. Change the mother's position from Fowler's to left lateral.
2. Insert a Foley catheter with the assistance of another nurse.
3. Notify the surgical team of an impending cesarean.
4. Decrease the IV of lactated Ringer's solution to 50 ml/hour.
Correct Answer: 1
Rationale 1: Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow.
Rationale 2: If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority.
Rationale 3: The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions.
Rationale 4: Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the patient is hypotensive. Decreasing the IV rate will not improve fetal heart tones.
You might also like to view...
The nurse knows that working with clients through rehabilitation and recovery may cause a conflict in value systems. Which of the following circumstances may cause your personal values to influence your effectiveness when working with a client?
1. An insurance company that approves your plan of care for the client 2. A client who chooses a different plan of care than you have mapped out 3. A family that works closely with the treatment team 4. A client who agrees with your opinion on the plan of care
The toddler is receiving oxygen in a mist tent. One of the disadvantages of the tent is that it requires the nurse to:
a. remove the restless child. b. change wet bedding and clothing as needed. c. open the mist tent at least once an hour. d. keep all objects outside of the tent.
Which of the following can influence a patient's response to drug therapy? Select all that apply
a. Body weight b. Genetics c. Body rhythms d. Psychosocial considerations e. Smoking and/or alcohol intake f. Bioavailability g. Dosage h. Literacy level of patient
Order: Increase patient's current dose of citalopram (20 mg) po daily by 20 mg per day starting next dose. See label for dose on hand.The new amount to administer is ________.
Fill in the blank(s) with the appropriate word(s).