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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Correct Answer is A

Explanation

Choice A: The correct answer is (a) Bleeding. The purpose of administering vitamin K to a newborn following delivery is to prevent bleeding complications. Vitamin K plays a crucial role in the synthesis of blood clotting factors, specifically factors II, VII, IX, and X. Newborns have low levels of vitamin K at birth, and it takes a few days for their bodies to start producing it. This places them at risk of developing vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including bleeding into the brain (intracranial haemorrhage). By giving the newborn a vitamin K injection, this deficiency is corrected, reducing the risk of bleeding complications.

Choice B rationale

(b) Infection. Administering vitamin K to a newborn is not intended to prevent infections. Vitamin K is essential for blood clotting and does not have a direct role in preventing or treating infections. Infection prevention measures involve proper hygiene practices and vaccination, but vitamin K is unrelated to this aspect of care.

Choice C rationale

(c) Potassium deficiency. Administering vitamin K to a newborn has no impact on potassium levels. Potassium is a different essential nutrient that plays a vital role in various physiological processes, but it is not related to blood clotting. The administration of vitamin K is specific to preventing bleeding complications, not addressing potassium deficiency.

Choice D rationale

(d) Hyperbilirubinemia. The correct answer is not (d) Hyperbilirubinemia. Vitamin K administration is not aimed at preventing or treating hyperbilirubinemia, a condition characterized by elevated levels of bilirubin in the blood. Hyperbilirubinemia is related to the breakdown of red blood cells and the liver'sability to process bilirubin, whereas vitamin K's primary role is in the clotting cascade.

A. The client is Rh positive and the newborn is Rh negative. B. The client is Rh negative and the newborn is Rh positive. C. The client is Rh negative and the newborn is Rh negative. D. The client is Rh positive and the newborn is Rh positive.

Correct Answer is B

Explanation

Choice A rationale:

If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.

Choice B rationale:

This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.

Choice C rationale:

If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.

Choice D rationale:

If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.

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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

A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Correct Answer is B

Explanation

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