Author Question: The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that ... (Read 86 times)

washai · **on:** Jul 22, 2018

The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip.

Based on this finding, the nurse pre-pares for which most appropriate nursing actions? 1. Placing the mother in a supine position
2. Administering oxygen via face mask
3. Increasing the rate of the intravenous (IV) oxytocin infusion
4. Documenting the findings and continuing to monitor the fetal patterns

Question 2

The nurse who is collecting data from the client notes that the client's left-sided eyelid is drooping. The nurse documents that the client is exhibiting which of the following conditions?

1. Ptosis
2. Arcus senilis
3. Abnormal corneal reflex
4. Blockage of the lacrimal duct

amanda_14 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2

Rationale: Late decelerations are caused by uteroplacental insufficiency as the result of de-creased blood flow and oxygen to the fetus during the uterine contractions. This causes hypox-emia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late de-celeration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Documenting the findings and continuing to monitor the fetal patterns would delay necessary treatment.

Answer to Question 2

1

Rationale: Ptosis is a sagging of the upper lid of the eye so that it covers part of the pupil. It can be caused by edema, third cranial nerve disorders, or neuromuscular disorders. It is not caused by blockage of the lacrimal duct (tear duct). Arcus senilis is an age-related change, characterized by formation of a yellow-gray ring around the periphery of the cornea surrounding the iris. The corneal reflex is the blink reflex.