A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)

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Question 1 of 4

A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)

Correct Answer: A

Rationale: Rationale: A client at 42 weeks of gestation is at risk for oligohydramnios, which is associated with decreased amniotic fluid levels. Amnioinfusion can be used to increase amniotic fluid volume to prevent fetal cord compression and facilitate fetal movement during labor. Summary: - B: Hydramnios (excessive amniotic fluid) does not require amnioinfusion. - C: Fetal cord compression is a reason for amnioinfusion, not a condition to prepare for. - D: Polyhydramnios (excessive amniotic fluid) does not typically require amnioinfusion unless there are complicating factors.

Question 2 of 4

When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?

Correct Answer: C

Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.

Question 3 of 4

During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

Correct Answer: A

Rationale: The correct answer is A: Maternal fever. Maternal fever can lead to tachycardia in the fetus due to the transfer of maternal antibodies, cytokines, and other inflammatory mediators across the placenta, affecting fetal heart rate. Maternal fever can indicate infection, which can cause fetal distress. The other choices are incorrect because: B: Fetal heart failure typically presents with bradycardia, not tachycardia. C: Maternal hypoglycemia can affect the fetus but is more likely to cause fetal bradycardia than tachycardia. D: Fetal head compression can result in decelerations but not necessarily tachycardia.

Question 4 of 4

A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?

Correct Answer: A

Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress. Summary of other choices: B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring. C: Inserting an IV catheter is important but not the priority when late decelerations are observed. D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.

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