A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate?
Document the findings and tell the mother that the monitor indicates fetal well-being
Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen
Notify the physician or nurse midwife of the findings
Reposition the mother and check the monitor for changes in the fetal tracing
The Correct Answer is A
A. Document the findings and tell the mother that the monitor indicates fetal well-being: Episodic accelerations are transient increases in fetal heart rate at least 15 beats above baseline lasting 15 seconds. These are highly predictive of adequate fetal oxygenation and an intact central nervous system. No medical intervention is required for this reassuring pattern.
B. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen: Accelerations indicate that the fetus is already well-oxygenated and responding appropriately to stimuli or movement. Restricting maternal movement is unnecessary and does not improve fetal status in the presence of a reactive tracing. Fetal well-being is already clearly established.
C. Notify the physician or nurse midwife of the findings: Clinical notification is reserved for non-reassuring patterns such as late decelerations, bradycardia, or loss of variability. Accelerations are a normal finding in a healthy laboring client and do not require a change in the plan of care. Documentation is the standard protocol.
D. Reposition the mother and check the monitor for changes in the fetal tracing: Intrauterine resuscitation maneuvers like repositioning are used to correct decelerations or fetal distress. Since accelerations are a sign of health, changing the mother's position to "correct" the tracing is counterproductive. The current fetal heart rate pattern is optimal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. adolescents with a breech presentation: Breech presentation in a singleton pregnancy is typically managed via external version or cesarean section. Internal version is an invasive procedure with high risks of uterine rupture and hemorrhage. It is not indicated for routine singleton malpresentations regardless of maternal age.
B. response to fetal distress: Acute fetal distress requires the most rapid and least traumatic delivery method available. Internal version is technically difficult and can worsen fetal trauma or cause placental abruption. It is not an appropriate emergency response for a distressed singleton fetus.
C. multiple gestation, for the birth of the second twin: This maneuver is reserved for delivering a non-vertex second twin after the first twin is born. The clinician reaches into the uterus to pull the fetus into a footling breech for delivery. It is possible due to the dilated cervix.
D. obstetric intensive care unit for delivery of baby in fetal distress: The setting of the delivery does not change the indications for this high-risk maneuver. Internal version is not standard for fetal distress in a singleton pregnancy. It is specifically a tool for managing the delivery of the second twin.
Correct Answer is C
Explanation
A. achieving attitude: Attitude describes the degree of flexion or extension of the fetal head. Station refers specifically to the descent of the presenting part along the pelvic axis. These are distinct clinical assessments during a vaginal examination of a laboring patient.
B. reaching ballottement: This term describes a floating fetal part that rebounds when pushed during an examination. A head at +2 station is firmly engaged in the mid-pelvis and is no longer ballotable. It signifies advanced descent rather than a floating or unengaged fetus.
C. below the ischial spines: The ischial spines serve as the zero-point landmark for fetal station. Positive numbers indicate the number of centimeters the presenting part has descended past this point toward the pelvic outlet. A +2 station confirms the head is below the spines.
D. floating above "0" station: Negative numbers are used to indicate that the fetus is still high in the pelvis or floating. A +2 reading is a positive value, meaning the head has passed the midpoint of the pelvis. This confirms the fetus is descending.
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