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 B
Explanation
Choice A: Bowel prep protocols are not required for an amniocentesis procedure, as it involves sampling amniotic fluid from the uterus, not the bowel.
Choice B: Emptying the bladder before the procedure is important to improve comfort and minimize the risk of accidental puncture during the amniocentesis.
Choice C: It is essential to have a full bladder for some ultrasound procedures, but it is not necessary for an amniocentesis. A full bladder can help push the uterus upward and make it easier to visualize the fetus during the ultrasound, but it is not relevant to the amniocentesis procedure.
Choice D: Washing the abdomen with soap and water is not a required step for an amniocentesis procedure. The procedure involves sterile preparation of the abdomen using an antiseptic
solution.
Correct Answer is A
Explanation
A) All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B) A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C) A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D) A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.
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