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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.

Answer and Explanation

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)

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Correct Answer is C

Explanation

The correct answer is choice C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.This is based on therooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.

Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation.It is not related to muscle tone or reflexes.

Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation.Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.

Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning.They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.

A. Take the patient’s blood pressure. B. Have the patient breathe into her cupped hands. C. Help the patient to turn onto her side. D. Elevate the patient’s legs. E. Elevate the patient’s legs.

Correct Answer is C

Explanation

This is because the patient is experiencing supine hypotension syndrome, which occurs when the weight of the gravid uterus compresses the inferior vena cava and reduces venous return and cardiac output. Turning the patient onto her side will relieve the pressure and improve blood flow.

Choice A is wrong because taking the patient’s blood pressure will not address the cause of her symptoms and may delay appropriate intervention.

Choice B is wrong because breathing into her cupped hands will not improve her circulation and may increase her carbon dioxide levels.

Choice D is wrong because elevating the patient’s legs will not relieve the compression of the inferior vena cava and may worsen her condition.Normal blood pressure for a pregnant woman is 110/70 to 120/80 mmHg.Normal heart rate for a pregnant woman is 60 to 90 beats per minute.Normal respiratory rate for a pregnant woman is 16 to 24 breaths per minute.

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A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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