Question: A 32-year-old multigravida client who is at 40 weeks gestation is in early labor. The nurse assesses a fetal heart rate of 90 beats per minute for the last half of the previous three contractions. Which action should the nurse take?
1. Place her in the supine position and prepare an oxytocin infusion.
2. Place her on her left side and administer oxygen.
3. Place her in the knee-chest position and continue to monitor.
4. Place her in the lithotomy position and perform a vaginal examination.
Answer: 2
Rationale: This situation describes late decelerations of the fetal heart rate, which may indicate uteroplacental insufficiency. If this is noted, the nurse may turn the mother onto her left side and administer oxygen to help decrease stress on the fetus. If the client is receiving an oxytocic agent, it should be discontinued at this time. The situation is an emergency and the actions described in answer options 1, 3, and 4 are either incorrect or not effective to treat fetal distress.
Cognitive Level: Analysis
Nursing Process: Implementation
NCLEX Test Plan Category: Health Promotion and Maintenance
This week’s NCLEX exam practice question came from:
Manno: Mosby's Review Cards for the NCLEX-RN Exam, 3rd Edition, Maternal and Neonatal Nursing- Card 315, Question 65
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