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 C
Explanation
Choice A rationale
Male condoms are effective in preventing pregnancy and sexually transmitted infections, but their reliability can be compromised by improper use or breakage.
Choice B rationale
Vaginal rings provide hormonal contraception and are effective, but they may be less reliable compared to implants due to potential for incorrect use.
Choice C rationale
Hormonal implants are highly reliable because they provide continuous contraception over an extended period (up to 3-5 years) with minimal user intervention.
Choice D rationale
Oral contraceptives are effective when taken correctly, but their reliability can be reduced by missed doses or incorrect use.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Rapid weight gain during pregnancy, especially when accompanied by other symptoms, can be a sign of preeclampsia. This condition is characterized by high blood pressure and often occurs after 20 weeks of gestation. Reporting rapid weight gain is important for early detection and management.
Choice B rationale:
Visual disturbances, such as blurred vision, can be a warning sign of preeclampsia. It indicates potential neurological involvement and requires immediate evaluation to prevent complications for both the mother and the fetus.
Choice C rationale:
Elevated blood pressure readings are a critical sign of preeclampsia, a condition that can lead to serious health complications for both the mother and the baby if left untreated. Reporting elevated blood pressure is essential for early intervention and management.
Choice D rationale:
While the respiratory rate is slightly elevated, it is not as critical an indicator of preeclampsia as the other findings. In this case, the focus should be on more concerning symptoms, such as blood pressure and visual disturbances.
Choice E rationale:
Hyperactive deep tendon reflexes (3+) are a clinical sign of preeclampsia. The absence of clonus is a reassuring sign, but the presence of hyperactive reflexes warrants further evaluation and monitoring.
Choice F rationale:
The fetal heart rate (FHT) of 148/min is within the normal range (110-160/min) and does not indicate an immediate concern that needs to be reported. The nurse should focus on the maternal symptoms that suggest preeclampsia.
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