A nurse is caring for a client who is in active labor and notes late decelerations in the FRH on the external fetal.... Which of the following actions should the nurse take first?

Correct Answer: A

Rationale: The correct answer is A: Change the client's position. Late decelerations indicate uteroplacental insufficiency, which can be caused by pressure on the vena cava from the uterus. Changing the client's position can alleviate this pressure, improving fetal oxygenation. Palpating the uterus or increasing IV infusion rate may not address the underlying issue. Administering oxygen is important but should come after addressing the positional issue to ensure optimal oxygen delivery to the fetus.

Correct Answer: C

Rationale: Correct Answer: C. "I am experiencing suicidal thoughts." Rationale: This statement indicates a serious mental health concern that requires immediate follow-up. Suicidal thoughts during pregnancy can be a sign of depression or other mental health issues that need to be addressed promptly to ensure the safety and well-being of the client and the baby. Summary of Other Choices: A: "I have been crying the week of my period." - This statement suggests premenstrual symptoms which are common and not necessarily alarming during pregnancy. B: "I should gain 2 to 4 pounds in the first trimester and half a pound per week in the last two trimesters." - This statement reflects a correct understanding of weight gain recommendations during pregnancy and does not raise immediate concerns. D: "My menstrual cycle is 1 week late." - This statement is not concerning during pregnancy as menstrual cycles typically stop during pregnancy.

Correct Answer: C

Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix): 1. It is crucial to monitor the progress of labor by assessing cervical dilation. 2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push. 3. This information guides the healthcare team in providing appropriate care and support during delivery. 4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority. Summary: - Option A is incorrect because assessing fetal station is not the immediate next step. - Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action. - Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.

Correct Answer: D

Rationale: The correct answer is D because it involves the patient in the decision-making process by asking for their readiness to make a decision after discussing the medication. This approach respects the patient's autonomy and encourages them to actively participate in their healthcare choices. A is incorrect as it does not involve the patient in the decision-making process but rather imposes the provider's choice. B is incorrect as it uses authority to influence the patient's decision, which is not in line with shared decision making. C is incorrect as it focuses on convenience rather than involving the patient in the decision-making process.

Correct Answer: D

Rationale: Step-by-step rationale for why answer D is correct: 1. A triple screen test includes assessing alpha-fetoprotein, hCG, and estriol levels. 2. These values help determine the risk for neural tube defects and chromosomal trisomies. 3. The test does not directly diagnose spina bifida but assesses neural tube defects. 4. Down syndrome risk is also evaluated, not diagnosed directly. 5. Answer D provides a comprehensive explanation of the test components and its purpose, aligning with the test's actual function. Summary of why other choices are incorrect: A. Incorrect because the test screens for neural tube defects and chromosomal trisomies, not just spina bifida. B. Incorrect because the test is a screening tool for specific conditions, not a definitive diagnostic test. C. Incorrect because the test assesses multiple conditions, not just Down syndrome specifically.