A nurse is caring for a client in labor who has an internal fetal scalp electrode applied for continuous fetal heart rate (FHR) monitoring.
The nurse notes a pattern of late decelerations on the FHR tracing.
What is the priority nursing intervention?
Change the client's position.
Administer oxygen via face mask
Increase intravenous fluid rate.
Notify the health care provider.
The Correct Answer is D
Notify the health care provider. Late decelerations are a sign of uteroplacental insufficiency, which means that the blood flow and oxygen supply to the placenta and the fetus are compromised. This is a serious condition that can lead to fetal hypoxia and acidosis. The priority nursing intervention is to inform the health care provider who can assess the situation and decide on the appropriate course of action, such as delivery by cesarean section.
Choice A is wrong because changing the client’s position may not improve the blood flow to the placenta if there is a problem with the placenta itself, such as placental abruption.
Choice B is wrong because administering oxygen via face mask may not be enough to correct the fetal hypoxia caused by uteroplacental insufficiency.
Choice C is wrong because increasing intravenous fluid rate may not improve the blood flow to the placenta if there is a problem with the maternal blood pressure, such as hypotension from epidural analgesia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Place the device over the fetal back for 3 seconds.This is because vibroacoustic stimulation (VAS) is the application of a vibratory sound stimulus to the abdomen of a pregnant woman to induce fetal heart rate (FHR) accelerations.The presence of FHR accelerations reliably predicts the absence of fetal metabolic acidemia.VAS is typically used during a nonstress test (NST) to assess fetal well-being.The device should be placed over the fetal back for 3 seconds, as this is the optimal duration and location to elicit a fetal response.
Choice B is wrong because holding the device firmly against the maternal abdomen for 10 seconds may be too long and too strong for the fetus, and may cause discomfort or distress.
Choice C is wrong because moving the device around the maternal abdomen until fetal movement is detected may not be effective or efficient, as the device may not reach the optimal location or duration to stimulate the fetus.
Choice D is wrong because applying the device intermittently over the fundus for 15 seconds may not target the fetal auditory system, which is located near the fetal back, and may also be too long and too strong for the fetus.
Normal ranges for FHR are between 110 and 160 beats per minute, and FHR accelerations are defined as an increase of at least 15 beats per minute above baseline for at least 15 seconds.
Correct Answer is D
Explanation
Notify the provider and prepare for delivery.Oligohydramnios is a condition where the amniotic fluid volume is less than expected for gestational age and it is associated with maternal and fetal complications.
The nonstress test (NST) is a method of fetal surveillance that measures the fetal heart rate response to fetal movement.A reactive NST is defined as at least two accelerations of 15 beats per minute or more above the baseline, lasting 15 seconds or more, within a 20-minute period.
A nonreactive NST indicates fetal hypoxia or acidosis and requires further evaluation.An acoustic stimulator can be used to elicit fetal movement and accelerations, but it should not be repeated more than once in a 10-minute period.
Therefore, choice A is wrong because repeating the acoustic stimulation after 1 minute is too soon and may cause fetal distress.
Choice B is wrong because documenting the finding as a nonreactive NST is not enough to address the situation.Choice C is wrong because performing a contraction stress test (CST) is contraindicated in oligohydramnios because it may cause umbilical cord compression and fetal compromise.
The CST involves inducing uterine contractions with oxytocin or nipple stimulation and monitoring the fetal heart rate for signs of intolerance.
A negative CST means that there
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