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 B
Explanation
Choice A rationale
Telling the adolescent that wearing the brace is mandatory and refusal is noncompliant behavior can lead to defiance and resentment. This approach fails to acknowledge the adolescent's autonomy and emotional well-being, potentially decreasing adherence due to a feeling of being controlled rather than empowered in their own care.
Choice B rationale
Encouraging expression of feelings provides a safe space for the adolescent to process the emotional challenges associated with brace wear. Connecting with a peer support group offers validation and coping strategies from individuals facing similar experiences, promoting a sense of community and reducing feelings of isolation, thereby improving adherence.
Choice C rationale
Advising the mother to monitor brace usage closely and report nonadherence shifts the responsibility to the parent, potentially fostering conflict and reducing the adolescent's sense of ownership over their treatment. This approach can also lead to increased family tension and further resistance from the adolescent.
Choice D rationale
Emphasizing the importance of brace wear for spinal correction and future mobility is crucial for understanding the therapeutic benefits. However, this cognitive understanding alone may not be sufficient to address the psychosocial and emotional challenges adolescents face, which significantly influence adherence to a restrictive treatment like bracing.
Correct Answer is B
Explanation
Choice A rationale
Excessive dental caries and enlarged tonsils are more commonly associated with bulimia nervosa due to the erosive effects of recurrent vomiting on tooth enamel and compensatory hypertrophy of lymphoid tissue in the pharynx. While indicative of disordered eating, they are not primary physical markers for anorexia nervosa.
Choice B rationale
A skeletal appearance with lanugo on arms is highly indicative of anorexia nervosa. The emaciation results from severe caloric restriction, leading to significant adipose tissue and muscle loss. Lanugo, fine downy hair, develops as a compensatory mechanism to conserve body heat due to the lack of insulating fat.
Choice C rationale
An irregular heart rate, such as bradycardia, is a common finding in anorexia nervosa due to metabolic slowdown and electrolyte imbalances. However, heavy menstruation (menorrhagia) is not typically associated with anorexia; amenorrhea (absence of menstruation) is a classic sign due to hormonal suppression from malnutrition.
Choice D rationale
Being overweight with a puffy face is inconsistent with the diagnostic criteria for anorexia nervosa, which is characterized by significantly low body weight. A puffy face might suggest fluid retention or salivary gland enlargement, which can occur in bulimia, but not typical for anorexia.
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.