Please help . I will take the NCLEX soon and I have come across some conflicting information. The KAPLAN question below indicates that with late decelerations during labor, the first thing we should do is shut off the pitocin. However the KAPLAN book as well as other web resources, including this thread at AllNurses (http://allnurses.com/general-nursing...015-page2.html
), indicates that the order of interventions should be :
1. LLR position
2. O2 @ 8-10 LPM
3. Increase IV Fluid
4. Pit off
5. Call MD
You switch to the LLR first because it is the quickest and easiest intervention to take and do that while you get her oxygen going. Then you keep going down the list.
The nurse cares for a client in labor undergoing augmentation. The nurse notes 3 consecutive late decelerations on the client’s electronic fetal monitor tracing. Which of the following actions should the nurse take FIRST?
1. Turn off the infusion of oxytocin (Pitocin).
2. Turn the client to her left side.
3. Apply O2 by mask at 10 L of oxygen.
4. Increase the infusion of lactated Ringer’s solution.
1) CORRECT - priority action; cause must be stopped before implementing measures to increase oxygen flow to the fetus
2) increase placental perfusion, but must stop Pitocin first
3) increase the amount of circulating oxygen; but must stop Pitocin first
4) increasing the rate of fluid administration not indicated; used for fluid volume deficit
What will the NCLEX test expect? Thank you.