A nurse is assisting in the care of a client who is in active labour. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following is a cause of variable decelerations.

Fetal head compression.

Umbilical cord compression.

Maternal fever.

Polyhydramnios.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Choice A, fetal head compression, is not the correct answer in this case. Fetal head compression can cause early decelerations in the FHR, not variable decelerations. Early decelerations are often a result of the fetal head being compressed during contractions and are considered benign and expected during labor.

Choice B rationale:

The correct answer is choice B, which is umbilical cord compression. Variable decelerations of the fetal heart rate (FHR) can occur during labor due to various rationales, and umbilical cord compression is one of the common causes. When the umbilical cord gets compressed, it can briefly reduce or restrict the blood flow and oxygen supply to the fetus, leading to temporary decelerations in the FHR.

Choice C rationale:

Choice C, maternal fever, is also not the correct answer for variable decelerations in FHR. Maternal fever can be a sign of infection, and it may lead to other fetal heart rate abnormalities, such as tachycardia (an increased heart rate), but it is not specifically associated with variable decelerations.

Choice D rationale:

Choice D, polyhydramnios, is not the cause of variable decelerations in this scenario. Polyhydramnios refers to an excessive accumulation of amniotic fluid around the fetus. While it can have implications for pregnancy, it is not directly linked to variable decelerations of the FHR.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Step 1 is assessing heart rate. A heart rate of 130/min earns 2 points since a rate above 100/min is optimal.

Step 2 is assessing respiratory effort. A lusty cry earns 2 points as strong crying indicates good respiratory function.

Step 3 is assessing muscle tone. Flexed extremities earn 1 point since full active movement would score 2.

Step 4 is assessing reflex irritability. Grimace when suctioned earns 1 point as a vigorous response (cough, sneeze) would score 2.

Step 5 is assessing color. Acrocyanosis earns 1 point since a fully pink body scores 2.

Final answer: 7

A. Blood pressure. B. Cerebral manifestations. C. Fetal heart rate. D. Respiratory rate. E. Deep tendon reflexes. F. Gastrointestinal assessment findings.

Correct Answer is C

Explanation

Choice A reason:
Blood pressure. The nurse does not need to report the blood pressure because it is not mentioned in the given information that there is any abnormality or concern related to the client's blood pressure. Therefore, it is not a priority finding to report.
Choice B reason:
Cerebral manifestations. There is no mention of cerebral manifestations in the nurse's notes. Since there are no reported neurological symptoms or abnormalities, the nurse does not need to report cerebral manifestations to the provider.
Choice C reason:
Fetal heart rate. The nurse should report the fetal heart rate to the provider because it is an essential parameter to monitor during prenatal care. A normal fetal heart rate ranges from 110 to 160 beats per minute, and in this case, the fetal heart rate is 158/min, which falls within the normal range. However, it is still necessary to inform the provider about this vital sign for documentation and reassurance.
Choice D reason:
Respiratory rate. The respiratory rate is not mentioned in the nurse's notes, and there are no indications of any respiratory issues or concerns. Therefore, it is not necessary to report the respiratory rate to the provider based on the information provided.
Choice E reason:
Deep tendon reflexes. The nurse notes that the patellar reflex is 3+ and clonus is negative. These findings are within the normal range and do not require reporting to the provider.
Choice F reason:
Gastrointestinal assessment findings. The nurse's notes do not mention any abnormal gastrointestinal assessment findings. Since there are no indications of gastrointestinal issues, the nurse does not need to report any gastrointestinal findings to the provider.

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A nurse is assisting in the care of a client who is in active labour. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following is a cause of variable decelerations.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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