A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?
Recurrent variable deceleration of the FHR
Uterine contractions every 6 min
Uterine contractions lasting 30 to 45 seconds
Moderate variability of the FHR
The Correct Answer is A
A. Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B. Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C. Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D. Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. There is no fasting requirement for a nonstress test.
B. The client will press a button whenever they feel the baby move during the test to help correlate fetal movement with changes in the fetal heart rate.
C. A nonstress test is not meant to stimulate contractions. It monitors the fetal heart rate in response to the baby's movements.
D. While the client will be monitored, they are not required to lie flat on their back for the entire duration of the test. They may be in a semi-reclining or comfortable position.
Correct Answer is ["A","B","D"]
Explanation
A. Correct. Large for gestational age (LGA. infants may have a higher risk of birth injuries, including ecchymosis (bruising) due to their size.
B. Correct. Encouraging breastfeeding is important for all newborns, including those who are large for gestational age.
C. This action is not specifically related to caring for a newborn who is large for gestational age. Meconium may be collected for other reasons, but it is not a priority in this situation.
D. Correct. LGA infants are at increased risk for hypoglycemia due to maternal gestational diabetes. Monitoring blood glucose levels is important.
E. This action is not typically indicated for newborns who are large for gestational age. It is important to focus on monitoring and providing supportive care unless there arespecific medical indications for a blood transfusion.
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