A nurse is assessing the fetal heart rate and uterine activity of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
Which of the following findings should the nurse report to the provider immediately?
Fetal heart rate of 140 beats per minute
Uterine contractions every 10 minutes
Fetal heart rate decelerations
Uterine contractions lasting 60 seconds
The Correct Answer is C
C. Fetal heart rate decelerations.
Fetal heart rate decelerations are temporary drops in the fetal heart rate that can indicate fetal distress or lack of oxygen. There are three types of decelerations: early, late and variable. Early decelerations are benign and caused by compression of the fetus’s head during a uterine contraction. Late decelerations are caused by uteroplacental insufficiency, which is a decrease in blood flow to the placenta. Variable decelerations are the most common type and vary in shape, duration and intensity. They are often caused by cord compression or other factors that affect fetal oxygenation.
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A. Fetal heart rate of 140 beats per minute.
Statement is wrong because this is a normal fetal heart rate. The normal range for fetal heart rate is 120-160 beats per minute.
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B. Uterine contractions every 10 minutes.
Statement is wrong because this is a normal frequency for uterine contractions during early labor.
The normal range for uterine contractions is 5-10 minutes apart.
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D. Uterine contractions lasting 60 seconds.
Statement is wrong because this is a normal duration for uterine contractions during active labor.
The normal range for uterine contractions is 45-90 seconds long.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Two or more accelerations of at least 15 beats/min above baseline lasting for at least 15 seconds in a 20-minute period.This indicates a reactive test, which means that the fetus is well oxygenated and not in distress.
Choice B is wrong because no accelerations or decelerations in a 20-minute period indicate a non-reactive test, which may suggest fetal hypoxia or acidosis.
Choice C is wrong because one acceleration of at least 10 beats/min above baseline lasting for at least 10 seconds in a 20-minute period is the criterion for a reactive test for gestational age less than 32 weeks, not 34 weeks.
Choice D is wrong because variable decelerations with normal variability in a 20-minute period indicate cord compression or fetal head compression, not a reactive test.
Correct Answer is A
Explanation
Turn the client to the side.This is because turning the client to the side will prevent aspiration and maintain a patent airway during a seizure.
Some possible explanations for the other choices are:
• Choice B. Insert an oral airway.This is wrong because inserting an oral airway during a seizure can cause injury to the client’s mouth or teeth, and it can also stimulate the gag reflex and increase the risk of vomiting and aspiration.
• Choice C. Administer oxygen via face mask.This is wrong because administering oxygen via face mask during a seizure can be difficult and ineffective, as the client may not be able to breathe through the mask or may dislodge it with their movements.Oxygen can be given after the seizure has stopped, if needed.
• Choice D. Document the duration of the seizure.
This is wrong because documenting the duration of the seizure is not a priority action during a seizure.The nurse should first ensure the client’s safety and airway patency, and then document the seizure characteristics after it has ended.
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