A nurse is caring for a 26-year-old female client in the labor and delivery unit. The client is gravida 2, para 1, term 1, living 1, and is admitted with cervical dilation of 4 cm, 70% effacement, and -1 station. The pregnancy has been uncomplicated.

Exhibits:

Exhibits

The nurse reviews the client data. Drag the word choices to complete the sentence.
Abnormal FHR patterns can result in
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,
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, and
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"E"}

Acidemia: Acidemia refers to an abnormal acidity in the blood (pH < 7.35). Prolonged abnormal FHR patterns can indicate insufficient oxygen delivery to the fetus, leading to anaerobic metabolism and the production of lactic acid, causing acidemia. The normal fetal pH is around 7.30-7.35.

Hypoxemia: Hypoxemia is a reduced level of oxygen in the blood. Abnormal FHR patterns may signal that the fetus is not receiving adequate oxygen, potentially due to cord compression, placental insufficiency, or other factors affecting oxygen transfer. Normal oxygen saturation for a fetus is generally around 30-70%.

Hypoxia: Hypoxia is a condition where there is insufficient oxygen available to meet the metabolic needs of the fetus. Abnormal FHR patterns can indicate ongoing or impending hypoxia, which can lead to severe fetal distress and compromise. It is crucial to monitor and address such conditions promptly.

Rationale for Incorrect Answers:

Hypoglycemia: Hypoglycemia refers to low blood glucose levels (typically < 45 mg/dL in newborns). Abnormal FHR patterns are not directly associated with changes in glucose metabolism. Rather, hypoglycemia in neonates is often related to maternal diabetes, prematurity, or other metabolic disturbances.

Meconium Stool: Meconium-stained amniotic fluid is a possible indicator of fetal distress but is not a direct result of abnormal FHR patterns. Meconium passage may be associated with post-term pregnancy, fetal hypoxia, or other factors, but the direct consequences of abnormal FHR patterns are more specifically related to oxygenation and acid-base status.

Maternal Hypotension: Maternal hypotension, or low blood pressure (typically < 90/60 mm Hg), is a maternal condition that can affect fetal well-being if severe and prolonged. However, it is not a direct result of abnormal FHR patterns. Instead, maternal hypotension can contribute to abnormal FHR by impairing uteroplacental perfusion.

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Correct Answer is B

Explanation

Choice A rationale

Variable decelerations are abrupt decreases in fetal heart rate, unrelated to contractions and typically caused by umbilical cord compression. The described pattern does not match these characteristics.

Choice B rationale

Late decelerations occur when there is a gradual decrease in fetal heart rate starting after the contraction begins and returning to baseline after the contraction ends, often indicating utero-placental insufficiency.

Choice C rationale

No decelerations are present when there are no decreases in fetal heart rate. The scenario described includes a specific pattern of decelerations, making this choice incorrect.

Choice D rationale

Early decelerations are a gradual decrease in fetal heart rate that mirrors the contraction pattern, often caused by head compression during contractions. The pattern described does not fit early decelerations.

A. Bolus of 2 ml/kg glucose 10% IV. B. Feed immediately. C. Echocardiogram. D. Monitor for respiratory distress. E. Apply dextrose gel inside the baby’s cheek.

Correct Answer is E

Explanation

Choice A rationale

Administering a bolus of 2 ml/kg glucose 10% IV is important for hypoglycemia management, providing rapid glucose delivery. Normal blood glucose level for neonates is 45-90 mg/dL. Severe hypoglycemia requires immediate intervention.

Choice B rationale

Immediate feeding can stabilize blood glucose levels by providing a sustained energy source. Breastfeeding or formula feeding aids in maintaining glucose homeostasis, supporting neonatal metabolic needs and preventing hypoglycemia.

Choice C rationale

An echocardiogram is a non-invasive diagnostic test used to evaluate cardiac structure and function. It is not a priority intervention compared to managing hypoglycemia or respiratory distress, as it does not address immediate neonatal needs.

Choice D rationale

Monitoring for respiratory distress involves observing signs such as tachypnea, grunting, nasal flaring, and retractions. Early identification of respiratory issues is crucial in neonates to prevent complications like respiratory failure.

Choice E rationale

Applying dextrose gel inside the baby’s cheek can quickly raise blood glucose levels in cases of mild hypoglycemia. It is an effective short-term intervention for stabilizing blood glucose while preparing for further treatment.

Choice F rationale

Monitoring temperature every 30 minutes helps detect hypothermia or hyperthermia. Normal neonatal temperature is 36.5-37.5°C (97.7-99.5°F). Maintaining thermal stability is vital to prevent metabolic complications in newborns.

Choice G rationale

Contacting respiratory therapy for arterial blood gas (ABG) and oxygen therapy ensures proper oxygenation and ventilation. ABGs provide critical information on acid-base status, and oxygen therapy supports adequate tissue oxygenation.

Choice H rationale

Keeping the neonate in a warmer with bilirubin lights (phototherapy) treats hyperbilirubinemia by converting bilirubin into a water-soluble form for excretion. Normal bilirubin levels are <12 mg/dL in term neonates. It is not an immediate priority.

Choice I rationale

Transferring to a neonatal intensive care unit (NICU) provides specialized care, including advanced monitoring and interventions for critically ill neonates. NICUs have resources for managing complex medical conditions and ensuring optimal outcomes.

Choice J rationale

Measuring blood glucose levels is essential for assessing neonatal glucose status, especially in high-risk infants. Normal blood glucose levels for neonates are 45-90 mg/dL. Identifying hypoglycemia is critical for prompt treatment.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

Correct Answer is E

Explanation

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