A nurse is analyzing a fetal heart monitor strip and identifies a sinusoidal fetal heart rate pattern, which has been occurring for 30 min. Which of the following actions should the nurse take at this time?

Decrease the client's IV fluids

Prepare the client for an emergent birth.

Turn the client to a supine position

Document the findings.

Answer and Explanation

The Correct Answer is B

A) Decrease the client's IV fluids:
Sinusoidal fetal heart rate patterns are concerning and typically indicate severe fetal distress, which is often associated with conditions such as fetal anemia, hypoxia, or central nervous system (CNS) damage. Decreasing IV fluids is not an appropriate response to a sinusoidal pattern. The primary focus should be on fetal well-being, not fluid management, in this situation.

B) Prepare the client for an emergent birth:
This pattern is typically associated with severe fetal compromise and is an ominous sign. Immediate intervention is required, and emergent delivery may be necessary to prevent further fetal distress and potential harm. The nurse should promptly notify the healthcare provider and prepare the client for an emergency cesarean delivery or other urgent interventions.

C) Turn the client to a supine position:
The supine position is not recommended for managing fetal distress, as it may decrease uterine blood flow and worsen the situation, especially if the fetus is experiencing hypoxia. The appropriate intervention for addressing a sinusoidal heart rate pattern is not repositioning the client in a supine position, but rather preparing for emergency delivery and providing immediate support to stabilize both mother and fetus.

D) Document the findings:
While it is important to document any fetal heart rate pattern, sinusoidal patterns require immediate action. Documentation alone is not sufficient in this case, as it does not address the potential life-threatening situation for the fetus. The nurse should not delay action, and the focus should be on preparing for emergency birth and notifying the healthcare provider immediately.

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Correct Answer is ["33"]

Explanation

Given:

Total volume to infuse: 100 mL

Infusion time: 60 minutes

Drop factor of tubing: 20 gtt/mL

To find:

Drip rate (gtt/min)

Step 1: Calculate the total number of drops

Total drops = Total volume x Drop factor

Total drops = 100 mL x 20 gtt/mL = 2000 gtt

Step 2: Calculate the drip rate

Drip rate = Total drops / Infusion time in minutes

Drip rate = 2000 gtt / 60 minutes = 33.33 gtt/min

Step 3: Round to the nearest whole number

33 gtt/min.

A. at the umbilicus B. At a non-palpable depth C. just above the symphysis pubis D. just below the umbilicus

Correct Answer is D

Explanation

A) At the umbilicus:
After delivery, the fundus is typically located at or just below the umbilicus in the immediate postpartum period, but it will gradually descend over the next few days. By 8 hours postpartum, the fundus is often slightly below the umbilicus, not directly at the umbilicus. The fundus will continue to shrink in size and move downward toward the pelvic region as the uterus contracts and involutes.

B) At a non-palpable depth:
A fundus that is non-palpable is generally expected later in the postpartum period, typically by 10-14 days after delivery, as the uterus contracts and returns to its pre-pregnancy size. At 8 hours postpartum, the fundus is still palpable, generally just below the umbilicus, and should be evaluated for firmness and position.

C) Just above the symphysis pubis:
The fundus is usually higher than the symphysis pubis at 8 hours postpartum, as it is still in the process of descending from the higher position it occupied during pregnancy. It would be expected to be just below the umbilicus or about 1 to 2 finger widths below it. By the second or third day postpartum, the fundus begins to move lower toward the symphysis pubis as it continues to involute.

D) Just below the umbilicus:
Eight hours after delivery, the nurse should expect to palpate the fundus just below the umbilicus. This is a typical finding as the uterus begins to contract and shrink after the delivery of the placenta. The fundus will descend about 1-2 cm per day postpartum, so by 8 hours, it is usually just slightly below the level of the umbilicus.

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A nurse is analyzing a fetal heart monitor strip and identifies a sinusoidal fetal heart rate pattern, which has been occurring for 30 min. Which of the following actions should the nurse take at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Calculate the gravity rate for gentamycin 100 mg/100ml with secondary tubing (20gtts/mL) over 60 minutes.

Correct Answer is ["33"]

Explanation

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Correct Answer is D

Explanation

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