Boost Skills: NCLEX Daily Questions #21

November 21, 2024

Thursday

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The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply.

Notify the health care provider 5. Perform a nitrazine test

Discontinue the oxytocin infusion

Administer oxygen via a nonrebreather face mask

Perform a nitrazine test

Change maternal position to the left side

The mnemonic VEAL CHOP may help nurses recall causes of fetal heart rate (FHR) changes noted on monitor tracings. A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point (nadir) after the contraction peak, and then gradually returns to baseline. Late decelerations indicate impaired fetal oxygenation associated with decreased uteroplacental perfusion (eg, due to maternal hypotension after epidural placement or uterine tachysystole). Chronic uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may also cause late decelerations. Nursing actions to improve fetal perfusion and oxygenation include: Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity

(Option 3) Changing maternal position to the left side to relieve compression of the inferior vena cava. If the FHR tracing does not improve, a right-side position may be attempted

(Option 2) Administering oxygen at 8-10 L/min via nonrebreather face mask to promote fetal oxygenation

(Option 1) Giving prescribed IV bolus of lactated Ringer solution or normal saline to improve placental perfusion, especially during maternal hypotension Notifying the health care provider (Option 4)

(Option 5) Nitrazine pH tests are used to detect leaking amniotic fluid, most often if premature (prelabor) rupture of membranes is suspected. This client is at term and in active labor.

The mnemonic VEAL CHOP may help nurses recall causes of fetal heart rate (FHR) changes noted on monitor tracings. A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point (nadir) after the contraction peak, and then gradually returns to baseline. Late decelerations indicate impaired fetal oxygenation associated with decreased uteroplacental perfusion (eg, due to maternal hypotension after epidural placement or uterine tachysystole). Chronic uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may also cause late decelerations. Nursing actions to improve fetal perfusion and oxygenation include: Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity

(Option 3) Changing maternal position to the left side to relieve compression of the inferior vena cava. If the FHR tracing does not improve, a right-side position may be attempted

(Option 2) Administering oxygen at 8-10 L/min via nonrebreather face mask to promote fetal oxygenation

(Option 1) Giving prescribed IV bolus of lactated Ringer solution or normal saline to improve placental perfusion, especially during maternal hypotension Notifying the health care provider (Option 4)

(Option 5) Nitrazine pH tests are used to detect leaking amniotic fluid, most often if premature (prelabor) rupture of membranes is suspected. This client is at term and in active labor.

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