A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?
The fetal heart rate decreases after the start of a contraction and returns to the baseline 60 seconds after the end of the contraction.
There is a six to ten beat-to-beat variability in the fetal heart rate.
The fetal heart rate accelerates five to seven beats just prior to the beginning of a contraction.
The fetal heart rate decreases at the start of the contraction and returns to baseline by the end of the contraction.
The Correct Answer is A
The correct answer is choice A and it indicates fetal distress because it is a sign of late deceleration. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia and can lead to fetal acidosis and neurological damage.
Choice B is wrong because it indicates a normal variability in the fetal heart rate, which reflects a healthy autonomic nervous system. A normal fetal heart rate is 120-160 beats per minute.
Choice C is wrong because it indicates an early acceleration in the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.
Choice D is wrong because it indicates an early deceleration in the fetal heart rate, which is a normal response to fetal head compression during contractions.
It does not indicate fetal distress.
Normal ranges for fetal heart rate patterns are:
• Baseline: 120-160 beats per minute
• Variability: 6-25 beats per minute
• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds
• Decelerations: none or early (mirror contractions)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Auscultate the fetal heart sounds.This is because spontaneous rupture of membranes (SROM) may be associated with fetal distress or cord prolapse, and the nurse should assess the fetal well-being as soon as possible.Fetal heart sounds can indicate the presence of fetal bradycardia, tachycardia, or decelerations, which may require immediate intervention.
Choice A is wrong because checking the specific gravity of the amniotic fluid is not a priority action after SROM.The specific gravity can help differentiate amniotic fluid from urine, but it is not as reliable as other methods such as nitrazine paper test or visual inspection.
Choice B is wrong because providing dry linens for the patient is a comfort measure, but not a priority action after SROM.The nurse should first ensure the safety of the fetus and the mother before attending to their comfort needs.
Choice D is wrong because notifying the health care provider is an important action after SROM, but not the first one.The nurse should gather relevant data such as fetal heart rate, maternal vital signs, and characteristics of the fluid before contacting the provider.
Correct Answer is C
Explanation
The correct answer is choice C. Caloric intake should be 300 calories above the suggested non-pregnant caloric intake.This is because women with gestational diabetes need to meet the nutritional needs of pregnancy and also control their blood glucose levels.
Choice A is wrong because carbohydrates should make up about 45% of the total dietary intake for women with gestational diabetes, not 25%.
Carbohydrates are important for providing energy and nutrients for the mother and the baby.
Choice B is wrong because animal protein can be included in the pre-bedtime snack as long as it is combined with some carbohydrates.
Protein can help prevent low blood glucose levels during the night.
Choice D is wrong because sugar substitutes do not help to control blood glucose levels.They may also have adverse effects on the baby’s development.Women with gestational diabetes should limit their intake of added sugars and choose foods with natural sugars instead.
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