2024 ATI RN Maternity Newborn Exam 2 New Latest
Version with All Questions and 100% Correct
Answers and Rationale
Question 1:
The nurse is assisting in the care of a client who is in active labor. The nurse
notes late decelerations on the fetal monitor tracing. Which of the following
actions should the nurse take first?
A. Increase the infusion rate of the IV fluid
B. Position the client on her side
C. Administer oxygen via face mask
D. Elevate the client's legs
Show correct answer and explanation
Explanation
Choice A reason: This is incorrect. Increasing the infusion rate of the IV fluid is not
the first action the nurse should take. IV fluid can help increase the blood volume
and improve the placental perfusion, but it is not the most effective way to relieve
the uteroplacental insufficiency that causes late decelerations. It may also cause
fluid overload or edema in the mother or the fetus.
Choice B reason: This is correct. Positioning the client on her side is the first action
the nurse should take. Lateral position can reduce the compression of the inferior
vena cava and the aorta by the gravid uterus, which can improve the maternal
and fetal circulation. It can also enhance the uterine blood flow and oxygen
delivery to the fetus, which can prevent or correct fetal hypoxia.
Choice C reason: This is incorrect. Administering oxygen via face mask is not the
first action the nurse should take. Oxygen can increase the oxygen saturation
and the partial pressure of oxygen in the maternal blood, which can benefit the
fetus. However, it is not the most immediate way to address the cause of late
decelerations, which is the reduced blood flow to the placenta. It may also have
adverse effects, such as hyperoxia or oxidative stress.
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