A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring.The nurse observes that the fetal heart rate begins to slow at the start of a contraction and the nadir is at the same time as the peak of the contraction.
The FHR returns to the FHR baseline at the same time that the contraction ends.
The nurse should document this finding as which of the following?
Accelerations.
Late decelerations.
Early decelerations.
Variable decelerations.
The Correct Answer is C
Choice A rationale
Accelerations are increases in the fetal heart rate (FHR) above the baseline, typically in response to fetal movement or uterine contractions. They indicate a healthy, well-oxygenated fetus and are not consistent with the described pattern of decelerations.
Choice B rationale
Late decelerations are characterized by a gradual decrease in FHR that begins after the contraction has started, with the lowest point of the deceleration (nadir) occurring after the peak of the contraction. They are associated with uteroplacental insufficiency and fetal hypoxia, which is not described in the scenario.
Choice C rationale
Early decelerations are a gradual decrease in FHR that mirrors the contraction, starting with the contraction and returning to baseline as the contraction ends. The nadir of the deceleration occurs at the peak of the contraction, which fits the pattern described.
Choice D rationale
Variable decelerations are abrupt decreases in FHR that can occur at any time during the contraction cycle, usually due to umbilical cord compression. They are not uniform in relation to contractions and can vary in duration, depth, and timing, unlike the described pattern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Acknowledging the client’s feelings provides emotional support and validates her experience. This response opens the door for further discussion and support, which is crucial for emotional well-being.
Choice B rationale
Suggesting future possibilities does not address the client's current emotional state. It may come across as dismissive of her feelings and does not offer the immediate support she needs.
Choice C rationale
While emphasizing the health of the baby is positive, it can also be perceived as dismissive of the client's feelings and her disappointment about the birth experience.
Choice D rationale
Mentioning the resumption of sexual relations shifts the focus away from her emotional needs and can be inappropriate or insensitive in this context, failing to address her disappointment.
Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 10/min is concerning as it indicates possible respiratory depression, which can be a side effect of spinal anesthesia. This requires immediate intervention to prevent hypoxia and other complications.
Choice B rationale
Blood pressure of 100/70 mm Hg is within normal limits and does not require immediate intervention in this context.
Choice C rationale
Urinary output of 30 ml/hr is slightly low, but it is not immediately life-threatening. It may require monitoring and further assessment if it persists.
Choice D rationale
A headache pain rated a 6 on a scale of 0 to 10 could indicate a post-dural puncture headache, which is common after spinal anesthesia. It requires attention but is not an immediate life-threatening condition. .
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