A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
Variable decelerations are a result of the administration of IV narcotic analgesics.
Variable decelerations are related to fetal head compression.
Variable decelerations are due to umbilical cord compression.
Variable decelerations are caused by uteroplacental insufficiency.
The Correct Answer is C
A) Variable decelerations are a result of the administration of IV narcotic analgesics: IV narcotic analgesics can cause changes in the fetal heart rate, but they are more commonly associated with early decelerations, not variable decelerations.
B) Variable decelerations are related to fetal head compression: Fetal head compression is associated with early decelerations, not variable decelerations.
C) Variable decelerations are due to umbilical cord compression: This is the correct answer.
Variable decelerations occur due to compression of the umbilical cord during contractions, leading to transient decreases in fetal blood flow and oxygenation.
D) Variable decelerations are caused by uteroplacental insufficiency: Uteroplacental insufficiency is associated with late decelerations, not variable decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: A weight gain of about 1 pound per week is a general guideline for women with normal BMI. However, for a client with a BMI of 26.5, the recommended weight gain during pregnancy may differ.
Choice B: Gaining 11 to 20 pounds may not be sufficient for a client with a BMI of 26.5, as the recommended weight gain is slightly higher for women with a higher prepregnancy BMI.
Choice C: For a client with a BMI of 26.5, the recommended weight gain during pregnancy is approximately 15 to 25 pounds. This range is specific to women with a BMI in the overweight category.
Choice D: Gaining 25 to 35 pounds is recommended for clients with a lower BMI range (normal BMI). For a client with a BMI of 26.5, this amount of weight gain may be excessive.
Correct Answer is B
Explanation
A) The largest fetal diameter has passed through the pelvic outlet: This is an incorrect
interpretation of station 0. Station 0 means that the presenting part is at the level of the ischial spines, not fully descended through the pelvic outlet.
B) The lowermost portion of the presenting part is at the level of the ischial spines: This is the correct interpretation of station 0. Station 0 is the landmark at which the presenting part is at the level of the ischial spines in the maternal pelvis.
C) The posterior fontanel is palpable: The position of the fontanelle is not related to the station of the presenting part.
D) The fetal head is in the left occiput posterior position: The position of the fetal head is not indicated by the station measurement.
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