A nurse assisting on a labor unit is collecting data about the fetal heart rate pattern of a client in labor.
Which of the following findings should the nurse classify as nonreassuring fetal heart rate patterns? (Select All that Apply.)
Variable decelerations are present.
Early decelerations are present.
FHR variability is decreased.
Accelerations are absent.
Correct Answer : A,C,D,E
Choice A rationale
Variable decelerations are abrupt, unpredictable decreases in fetal heart rate, often V, W, or U shaped. They are caused by umbilical cord compression, which reduces umbilical blood flow, leading to hypoxia and acidemia. This compromises fetal oxygenation and can indicate fetal distress requiring intervention to optimize fetal well-being.
Choice B rationale
Early decelerations are symmetrical, gradual decreases in fetal heart rate that mirror uterine contractions. They are caused by head compression during labor, stimulating the vagus nerve and slowing the heart rate. This is generally considered a benign finding and indicates normal fetal response to uterine contractions.
Choice C rationale
Decreased fetal heart rate (FHR) variability refers to a reduction in the normal fluctuations of the FHR. This indicates reduced central nervous system (CNS) oxygenation and autonomic nervous system activity, often due to fetal hypoxia, acidemia, or CNS depressant medications. Sustained decreased variability is a significant nonreassuring sign.
Choice D rationale
Absent accelerations mean the fetal heart rate does not spontaneously increase by 15 beats per minute for at least 15 seconds. Fetal accelerations indicate a healthy, oxygenated fetal central nervous system and are a sign of fetal well-being. Their absence suggests potential fetal hypoxemia or acidosis.
Choice E rationale
A fetal heart rate baseline higher than expected, typically above 160 beats per minute, is classified as fetal tachycardia. This can be caused by maternal fever, infection, fetal hypoxia, or certain medications. Sustained tachycardia can increase fetal metabolic demand and potentially lead to fetal decompensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Continuous labor support, often provided by doulas or trained birth companions, significantly reduces perceived pain intensity. This is mediated by physiological mechanisms like decreased sympathetic nervous system activation, leading to lower circulating catecholamines, and increased release of endogenous opioids, which naturally mitigate pain signals by binding to mu-opioid receptors in the central nervous system.
Choice B rationale
The presence of a supportive individual during labor fosters a sense of security and control for the birthing person. This psychosocial benefit contributes to a more positive subjective experience, reducing feelings of isolation and fear. Emotional support can lead to increased coping efficacy and a greater sense of satisfaction with the birthing process.
Choice C rationale
Research indicates that continuous labor support is associated with better fetal outcomes, including a reduced incidence of fetal distress and fewer low Apgar scores. This may be attributed to decreased maternal stress hormone levels, which can negatively impact uterine blood flow and oxygen delivery to the fetus, thus promoting a more stable intrauterine environment.
Choice D rationale
Improved client outcomes encompass a range of positive effects, such as reduced rates of medical interventions like epidural anesthesia and cesarean sections. The presence of support often empowers the client to labor more effectively, leading to shorter labor durations and a decreased need for pharmacological pain management, contributing to overall maternal well-being.
Choice E rationale
Increased anxiety is an incorrect benefit. Scientific evidence consistently demonstrates that continuous support during labor actually reduces maternal anxiety and stress levels. The presence of a supportive individual provides emotional reassurance and practical assistance, which helps to alleviate fear and promote a sense of calm during the birthing process.
Correct Answer is B
Explanation
Choice A rationale
This describes an incomplete fracture, where the bone's continuity is not completely disrupted. The periosteum and some bone matrix remain intact, providing some structural continuity. This type of fracture often involves a "greenstick" injury in children, where one side of the bone fractures and the other side bends.
Choice B rationale
A complete fracture involves a full break through the bone, resulting in two or more distinct bone fragments that are no longer connected. This disruption compromises the structural integrity of the bone, leading to instability and potential displacement of the fragments.
Choice C rationale
This describes an open or compound fracture, where the fractured bone fragments penetrate the skin, creating an open wound. While often a complete fracture, the defining characteristic here is the skin penetration and increased risk of infection, not just the separation of fragments.
Choice D rationale
This describes a bend deformity or an incomplete fracture, often seen in children due to the greater flexibility of their bones compared to adults. The bone's plastic deformation allows it to bend without a complete break, preserving some structural continuity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
