Maternal-newborn nursing · practice question

A 29-year-old client in labor and delivery is being evaluated for labor with external fetal monitoring. Assessment data include late decelerations and minimal variability on fetal monitoring. Which nursing action should the nurse take first?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026maternal-newborn

Implement the final step of the care plan before assessing the client.Document the client as stable without reassessment.Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Answer and explanation

Correct answer

D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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A 29-year-old client in labor and delivery is being evaluated for labor with external fetal monitoring. Assessment data include late decelerations and minimal variability on fetal monitoring. Which nursing action should the nurse take first?

Correct answer

Why

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