A nurse is caring for a client who is in active labor.
The nurse notes early decelerations of the FHR on the fetal monitor tracing.
The nurse should identify that which of the following conditions causes early decelerations in the FHR?

Fetal hypoxemia.

Uteroplacental insufficiency.

Cord compression.

Head compression.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Fetal hypoxemia manifests as late decelerations, not early decelerations. Early decelerations are benign and do not indicate hypoxemia or oxygen deprivation.

Choice B rationale

Uteroplacental insufficiency causes late decelerations due to decreased oxygen delivery. Early decelerations are unrelated to this condition.

Choice C rationale

Cord compression results in variable decelerations due to intermittent blood flow obstruction. Early decelerations are not caused by cord issues.

Choice D rationale

Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions. .

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Correct Answer is B

Explanation

Choice A rationale

Intravenous medications are not administered for a nonstress test, which evaluates fetal heart rate response to movement using external monitoring. No pharmacological intervention is needed.

Choice B rationale

Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.

Choice C rationale

There are no dietary restrictions for a nonstress test, as the procedure involves non-invasive external monitoring and does not affect digestion or metabolic processes.

Choice D rationale

A nonstress test does not assess fetal lung maturity but evaluates fetal heart rate accelerations in response to fetal movement to ensure fetal well-being.

A. Check the newborn's temperature every 8 hours. B. Apply moisturizing lotion to the newborn's skin every 4 hours. C. Reposition the newborn every 2 to 3 hours. D. Give the newborn 1 oz of glucose water every 4 hours.

Correct Answer is C

Explanation

Choice A rationale

Checking the newborn’s temperature every 8 hours is insufficient during phototherapy. Frequent monitoring every 2-4 hours ensures proper thermoregulation, essential to preventing hypothermia or hyperthermia risks.

Choice B rationale

Moisturizing lotions can interfere with phototherapy by altering light penetration. Additionally, these products might increase the risk of skin irritation or chemical burns under light exposure.

Choice C rationale

Repositioning every 2-3 hours evenly exposes all skin areas to light, optimizing bilirubin breakdown and preventing pressure ulcers, ensuring effective phototherapy outcomes and skin integrity.

Choice D rationale

Glucose water is not recommended for hyperbilirubinemia management. Adequate hydration through breastfeeding or formula feeding ensures bilirubin excretion without interfering with feeding schedules or therapy effectiveness. .

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A nurse is caring for a client who is in active labor.The nurse notes early decelerations of the FHR on the fetal monitor tracing.The nurse should identify that which of the following conditions causes early decelerations in the FHR?

Nursing Test Bank

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A nurse is caring for a client who is in active labor.
The nurse notes early decelerations of the FHR on the fetal monitor tracing.
The nurse should identify that which of the following conditions causes early decelerations in the FHR?