A nurse is assisting in the care of a 28-year-old female client who is in active labor in the labor and delivery unit.
Complete the following sentence by using the lists of options.
The nurse should determine that the FHR pattern represents
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
The nurse should determine that the FHR pattern represents Early decelerations due to Fetal head compression during contractions.
Rationale for correct answers:
Early decelerations are a gradual decrease and return to baseline of the fetal heart rate (FHR) associated with uterine contractions. They mirror contractions, beginning and ending with the contraction. This pattern is physiologic and typically benign.
Fetal head compression during contractions causes a vagal response leading to early decelerations. At a station of +4 and full dilation, fetal descent is significant, making head compression the most likely cause.
Rationale for incorrect Response 1 Options:
Late decelerations occur after the peak of the contraction and are due to uteroplacental insufficiency. These are non-reassuring and do not mirror contractions, unlike what is noted in the case.
Variable decelerations are abrupt drops in FHR and vary in timing, shape, and duration. They are not mirror images and are often associated with cord compression, which is not supported by this case’s findings.
Prolonged decelerations last >2 minutes and <10 minutes. The decelerations in this case are transient (to 105 bpm) and resolve before the end of the contractions, ruling out prolonged patterns.
Rationale for incorrect Response 2 Options:
Umbilical cord compression leads to variable decelerations, which are abrupt and not aligned with contraction timing, unlike the current pattern.
Uteroplacental insufficiency results in late decelerations, which occur after the contraction ends. These are non-reassuring and not consistent with the current findings.
Maternal hypotension due to epidural could cause late decelerations from reduced placental perfusion. However, despite a BP drop at 0900 (100/52 mm Hg), the FHR deceleration pattern does not match.
Take home points:
- Early decelerations are benign and typically reflect fetal head compression during contractions.
- Differentiate early from late decelerations based on timing relative to contractions—early mirrors, late lags.
- Variable decelerations are abrupt and typically linked to umbilical cord compression, not head compression.
- Maternal hypotension from epidural requires close monitoring, but it leads to uteroplacental insufficiency and late decelerations, not early.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
According to Erik Erikson's theory of psychosocial development, adolescence (roughly ages 12-18) is characterized by the central crisis of identity versus role confusion. During this stage, adolescents explore various roles, beliefs, and values to form a cohesive sense of self and define their place in society, integrating past experiences with future aspirations.
Choice B rationale
Autonomy versus shame and doubt is the psychosocial crisis associated with early childhood, typically ages 1-3 years. During this stage, children develop a sense of personal control over physical skills and a sense of independence. Successful resolution leads to autonomy, while failure can result in feelings of shame and self-doubt.
Choice C rationale
Trust versus mistrust is the psychosocial crisis of infancy, typically ages 0-1 year. In this stage, infants develop a sense of trust in caregivers and the world based on the consistency and reliability of care received. Successful resolution fosters hope and security, while neglect can lead to mistrust and anxiety.
Choice D rationale
Industry versus inferiority is the psychosocial crisis characteristic of school age, typically ages 6-12 years. Children at this stage are focused on developing competence and mastering academic and social skills. Success in these endeavors leads to a sense of industry, while difficulties can result in feelings of inferiority and low self-esteem.
Correct Answer is B
Explanation
Choice A rationale
Active peer interaction generally indicates healthy social development and positive self-esteem in adolescents. Engagement with peers often provides opportunities for validation, belonging, and the development of social skills, all of which contribute positively to an individual's self-perception and confidence, rather than signaling struggles with self-esteem.
Choice B rationale
Isolation and negative body image are significant warning signs of self-esteem issues. Isolation indicates a withdrawal from social engagement, potentially due to feelings of inadequacy or fear of judgment. A negative body image reflects dissatisfaction with one's physical appearance, often leading to feelings of shame, anxiety, and low self-worth, which are central to poor self-esteem.
Choice C rationale
Choosing healthy foods is typically associated with positive health behaviors and a sense of self-care, which can be indicative of a healthy self-image and good self-esteem. Individuals with high self-esteem are more likely to prioritize their well-being and make choices that benefit their physical and mental health.
Choice D rationale
Frequent tantrums are more characteristic of younger children struggling with emotional regulation rather than adolescents with self-esteem issues. While adolescents can exhibit emotional outbursts, prolonged and frequent tantrums are less specific to self-esteem and more indicative of broader emotional or behavioral dysregulation issues in this age group.
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