The nurse is caring for a patient who is in labor and being externally monitored. What should the nurse do after noting early decelerations of the FHR?

Correct Answer: C

Rationale: The correct answer is C: Continue to monitor the patient. Early decelerations are benign and occur due to head compression during contractions. They are a normal response to fetal head compression and do not require any intervention as they are self-limiting. Continuing to monitor the patient allows the nurse to observe the pattern of decelerations and ensure they remain early and resolve on their own. Anticipating a cesarean birth (choice A) is unnecessary as early decelerations do not indicate fetal distress. Turning the patient onto the left side (choice B) is typically done for late decelerations, not early decelerations. Notifying the physician or nurse midwife immediately (choice D) is not necessary for early decelerations as they are expected and do not require immediate intervention.

Correct Answer: B

Rationale: The correct answer is B: Prepare for an emergency cesarean section. Uterine rupture during labor is a life-threatening emergency requiring immediate surgical intervention to prevent catastrophic outcomes for both the mother and the baby. A cesarean section is the most effective and timely intervention to address the uterine rupture and ensure the safety of both individuals. Administering pain relief medication (A) may be necessary but is not the most urgent intervention. Administering oxygen to the mother (C) can help with oxygenation, but it does not address the underlying issue of uterine rupture. Increasing IV fluid rate (D) may be helpful in some situations but is not the primary intervention needed to manage uterine rupture.

Correct Answer: D

Rationale: The correct answer is D because it addresses the potential causes of late decelerations comprehensively. Stopping Pitocin helps to eliminate uteroplacental insufficiency, administering oxygen improves fetal oxygenation, and changing the patient's position can alleviate pressure on the umbilical cord. Each intervention targets a different aspect contributing to late decelerations, making it crucial to implement all of them to optimize fetal well-being.

Correct Answer: B

Rationale: The correct answer is B: Maternal blood pressure. Before administering an epidural, it is crucial to assess the maternal blood pressure to ensure it is within the normal range. Hypotension can occur as a common side effect of epidural anesthesia, which can lead to decreased placental perfusion and compromise fetal oxygenation. Assessing maternal blood pressure helps in preventing potential complications. Incorrect choices: A: Cervical dilation - Not directly related to the administration of an epidural. C: Fetal heart rate - Important but not the immediate assessment needed before administering an epidural. D: Maternal temperature - While it is important in general assessment, it is not specifically required before giving an epidural.

Correct Answer: B

Rationale: The correct answer is B: Prepare the patient for immediate surgery. In the case of a ruptured uterus, prompt surgical intervention is crucial to control bleeding, repair the uterus, and prevent further complications such as hemorrhage and infection. Performing surgery is the priority over other interventions like administering fluids, pain relief medications, or performing a vaginal examination, as these actions do not address the immediate life-threatening situation of uterine rupture. Administering IV fluids may be necessary during surgery, and pain relief can be addressed post-operatively. Vaginal examination is contraindicated in cases of suspected uterine rupture as it can exacerbate the bleeding and worsen the condition.