A nurse is caring for a client who is in labor and is receiving epidural analgesia.
Which of the following changes in the FHR should the nurse report to the provider?
Prolonged period of absent FHR variability.
FHR increase to 150/min.
FHR accelerations of 15/min for 15 seconds.
Early decelerations of the FHR.
The Correct Answer is A
Choice A rationale
A prolonged period of absent FHR variability is a critical finding that the nurse must report to the provider immediately. Absent variability indicates a significant lack of fetal well-being, potentially due to severe hypoxia, acidosis, or neurological compromise. It necessitates prompt intervention to prevent adverse outcomes.
Choice B rationale
An FHR increase to 150/min is within the normal fetal heart rate range, which typically falls between 110 and 160 beats per minute. This finding alone does not indicate a problem and would not require reporting to the provider, as it suggests adequate fetal oxygenation and an appropriately reactive fetus.
Choice C rationale
FHR accelerations of 15/min for 15 seconds are a positive sign of fetal well-being. Accelerations indicate an intact fetal nervous system and adequate oxygenation. They are a reassuring finding and suggest that the fetus is tolerating the labor process well, therefore not requiring reporting.
Choice D rationale
Early decelerations of the FHR are typically benign and do not require reporting to the provider. These decelerations are usually associated with head compression during contractions and are characterized by a gradual decrease in FHR that mirrors the contraction, indicating a physiological response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Temperature instability, particularly hypothermia, is a significant indicator of neonatal hypoglycemia. Glucose is the primary metabolic fuel for thermogenesis, and its deficiency impairs the infant's ability to maintain core body temperature. The normal newborn temperature range is typically 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B rationale
Acrocyanosis, a bluish discoloration of the hands and feet, is a common and usually benign finding in newborns, especially in the first 24-48 hours, due to immature peripheral circulation. It does not directly indicate hypoglycemia; rather, it reflects normal physiological adaptation to extrauterine life.
Choice C rationale
Jitteriness, or tremors, is a classic neurological sign of hypoglycemia in newborns. The central nervous system is highly dependent on glucose for energy, and insufficient glucose supply can lead to neuronal excitability and involuntary muscle movements. This is often an early and prominent symptom.
Choice D rationale
Hypotonia, characterized by decreased muscle tone and floppiness, can be a symptom of severe or prolonged hypoglycemia. Glucose is essential for proper neuromuscular function, and its deprivation can impair nerve impulse transmission and muscle contraction, leading to reduced muscle resistance to passive movement.
Choice E rationale
Abdominal distention is typically associated with gastrointestinal issues such as feeding intolerance, bowel obstruction, or necrotizing enterocolitis. It is not a direct or common manifestation of hypoglycemia in newborns. Hypoglycemia primarily affects metabolic and neurological systems.
Correct Answer is C
Explanation
Choice A rationale
Dark and concentrated urine in an infant indicates inadequate hydration, which can be a sign of insufficient milk intake during breastfeeding. Well-hydrated infants, receiving adequate breast milk, typically produce urine that is pale yellow and dilute, not dark and concentrated. This reflects proper kidney function and fluid balance.
Choice B rationale
After effective breastfeeding, the breasts should feel softer and less engorged, not firm. The firmness before feeding is due to milk accumulation within the mammary glands. As the infant removes milk, the pressure decreases, leading to a softer breast texture, indicating successful milk transfer.
Choice C rationale
A tugging sensation during breastfeeding is a normal and expected physiological sign. This sensation results from the baby's effective latch and negative pressure creation, which draws milk from the milk ducts into the baby's mouth. It signifies proper milk ejection and efficient feeding.
Choice D rationale
Two to three wet diapers in a 24-hour period for a 5-day-old infant is indicative of insufficient fluid intake. A well-hydrated newborn at this age, receiving adequate breast milk, should typically have six to eight wet diapers per 24 hours, reflecting sufficient hydration and milk transfer.
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