A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?
Head compression
Fetal hypoxia
Abruptio placentae
Postmaturity
The Correct Answer is A
A.
A. Early decelerations are typically benign and occur in response to head compression during contractions. They mirror the uterine contractions and are not associated with fetal distress.
B. Fetal hypoxia is associated with variable or late decelerations, not early decelerations.
C. Abruptio placentae is a medical emergency characterized by premature separation of the placenta from the uterine wall, which can lead to late decelerations due to fetal hypoxia.
D. Postmaturity is a term used to describe a pregnancy that extends beyond 42 weeks gestation and is not directly related to fetal heart rate patterns during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- A: An INR of 1.1 is within the normal range, indicating normal blood clotting ability, which is essential for wound healing. A normal INR does not pose a risk for delayed wound healing.
- B: Hyperemesis can lead to dehydration and malnutrition, both of which are detrimental to wound healing. Dehydration reduces blood volume and flow, impairing the delivery of oxygen and nutrients to the wound site, while malnutrition can weaken the immune response and the formation of new tissue.
- C: An HbA1C level of 5.6% is at the high end of the normal range and does not typically indicate diabetes or impaired glucose control, which are risk factors for delayed wound healing.
- D: While uncontrolled pain can be a concern for patient comfort and may indirectly affect wound healing by reducing mobility, it is not a direct risk factor for delayed wound healing like hyperemesis is.
Correct Answer is A
Explanation
- A: A heart rate greater than 60/min indicates that the transcutaneous pacing is effectively maintaining a heart rate within a normal range, which is crucial for adequate cardiac output and systemic perfusion.
- B: While 2+ pedal pulses indicate good peripheral perfusion, they do not directly reflect the effectiveness of transcutaneous pacing in treating complete heart block.
- C: Pacer spikes should appear before the QRS complex to show that the pacing stimulus is being delivered appropriately. Spikes after the QRS complex suggest that the pacing is not capturing the heart effectively.
- D: Distended jugular veins would be more indicative of heart failure or fluid overload and do not directly relate to the effectiveness of pacing therapy.
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