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","B","C","D"]
Explanation
Choice A rationale
A personal or family history of breast cancer is a significant contraindication for hormonal contraceptive use due to the potential for exogenous hormones to stimulate hormone-sensitive cancers. Estrogen and progesterone can influence the growth of certain breast cancer types, making a thorough assessment of this history critical before prescribing hormonal contraception.
Choice B rationale
Numerous medications can interact with hormonal contraceptives, affecting their efficacy or increasing adverse effects. For instance, certain anticonvulsants, antibiotics, and antiretrovirals can accelerate the metabolism of hormonal contraceptives, reducing their effectiveness and increasing the risk of unintended pregnancy. Therefore, a comprehensive medication history is essential.
Choice C rationale
Smoking, especially in women over 35 years old, significantly increases the risk of serious cardiovascular adverse events such as myocardial infarction, stroke, and thromboembolism when combined with hormonal contraceptive use. Nicotine constricts blood vessels and promotes hypercoagulability, which is exacerbated by exogenous hormones.
Choice D rationale
Hypertension is a contraindication for many hormonal contraceptives, particularly those containing estrogen, as they can exacerbate elevated blood pressure and increase the risk of cardiovascular events. Hormonal contraceptives can affect the renin-angiotensin-aldosterone system, leading to fluid retention and increased vascular tone, thus worsening hypertension.
Choice E rationale
While excessive alcohol consumption can have various health consequences, it is not a direct contraindication to hormonal contraceptive use itself. It may, however, indirectly affect adherence to medication regimens or exacerbate other health issues. The primary concern with alcohol would be if it leads to liver impairment, which could affect hormone metabolism.
Correct Answer is A
Explanation
Choice A rationale
A fundus that is deviated to the right, boggy, and 2 cm above the umbilicus suggests a distended bladder is displacing the uterus, preventing it from contracting effectively. A full bladder inhibits uterine involution by impeding the muscle fibers from compressing blood vessels, leading to uterine atony and increasing the risk of postpartum hemorrhage. Normal bladder capacity is 300-500 mL.
Choice B rationale
Obtaining a stat hemoglobin level is not the immediate priority. While a boggy uterus can indicate blood loss, the primary issue here is likely bladder distension causing uterine atony. Addressing the cause of the uterine displacement (bladder distension) takes precedence over assessing the degree of blood loss, which would be a secondary consequence. A normal hemoglobin for a woman is typically 12.0 to 15.5 grams per deciliter.
Choice C rationale
Administering methylergometrine is not the first action. Methylergometrine is a uterotonic agent used to promote uterine contractions and prevent postpartum hemorrhage. However, if the uterus is displaced by a full bladder, the medication's effectiveness will be significantly reduced until the bladder is emptied. Treating the underlying cause is crucial before administering uterotonics.
Choice D rationale
Inserting an indwelling urinary catheter is a more invasive intervention than assisting the client to void. While a catheter might be necessary if the client cannot void independently, the initial and least invasive action should always be to encourage spontaneous urination. Catheterization carries risks of urinary tract infection and discomfort, so it's not the first-line intervention.
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