A nurse is collecting data from a fetal monitor strip and recognizes late decelerations.
Which of the following actions should the nurse expect to be taken at this time?
Reposition the client to a left lateral position.
Document the findings in the electronic health record.
Adjust the fetal monitor sensors.
Insert a fetal scalp electrode.
The Correct Answer is A
Choice A rationale
Repositioning the client to a left lateral position aims to improve uteroplacental perfusion by alleviating compression of the inferior vena cava by the gravid uterus. This enhances venous return to the mother's heart, increasing cardiac output and ultimately improving blood flow and oxygen delivery to the placenta and fetus, which can resolve late decelerations caused by uteroplacental insufficiency.
Choice B rationale
Documenting findings is a crucial nursing responsibility, but it is not the immediate intervention for addressing late decelerations. Scientific principles dictate that physiological stabilization takes precedence over documentation when fetal well-being is compromised. Documentation would follow after initial interventions are implemented to improve the fetal status.
Choice C rationale
Adjusting fetal monitor sensors might be necessary if the tracing is poor quality, but it does not directly address the physiological cause of late decelerations. Late decelerations reflect uteroplacental insufficiency, not merely a monitoring artifact. Addressing the underlying physiological compromise is the priority before troubleshooting equipment.
Choice D rationale
Inserting a fetal scalp electrode provides a more accurate assessment of fetal heart rate by directly monitoring the fetus. However, this is an invasive procedure and is typically considered after initial conservative measures, such as maternal repositioning and oxygen administration, have been attempted without resolution of the late decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Variable decelerations are abrupt, unpredictable decreases in fetal heart rate, often V, W, or U shaped. They are caused by umbilical cord compression, which reduces umbilical blood flow, leading to hypoxia and acidemia. This compromises fetal oxygenation and can indicate fetal distress requiring intervention to optimize fetal well-being.
Choice B rationale
Early decelerations are symmetrical, gradual decreases in fetal heart rate that mirror uterine contractions. They are caused by head compression during labor, stimulating the vagus nerve and slowing the heart rate. This is generally considered a benign finding and indicates normal fetal response to uterine contractions.
Choice C rationale
Decreased fetal heart rate (FHR) variability refers to a reduction in the normal fluctuations of the FHR. This indicates reduced central nervous system (CNS) oxygenation and autonomic nervous system activity, often due to fetal hypoxia, acidemia, or CNS depressant medications. Sustained decreased variability is a significant nonreassuring sign.
Choice D rationale
Absent accelerations mean the fetal heart rate does not spontaneously increase by 15 beats per minute for at least 15 seconds. Fetal accelerations indicate a healthy, oxygenated fetal central nervous system and are a sign of fetal well-being. Their absence suggests potential fetal hypoxemia or acidosis.
Choice E rationale
A fetal heart rate baseline higher than expected, typically above 160 beats per minute, is classified as fetal tachycardia. This can be caused by maternal fever, infection, fetal hypoxia, or certain medications. Sustained tachycardia can increase fetal metabolic demand and potentially lead to fetal decompensation.
Correct Answer is A
Explanation
Choice A rationale
Folic acid is a B vitamin crucial for proper neural tube closure during embryonic development, typically completed by the 28th day after conception. Adequate intake, ideally 400-800 mcg daily for women of childbearing age, significantly reduces the risk of neural tube defects like spina bifida and anencephaly by supporting DNA synthesis and repair.
Choice B rationale
Aspirin, while a non-steroidal anti-inflammatory drug, is not directly linked to neural tube defects. Its primary concern in pregnancy relates to potential bleeding risks, particularly in the third trimester, and premature closure of the ductus arteriosus, not neural tube formation.
Choice C rationale
Iron intake is essential for preventing maternal anemia during pregnancy, supporting increased red blood cell production, and fetal growth. However, iron supplementation does not have a direct preventative effect on neural tube defects, which are primarily associated with inadequate folate metabolism, not iron deficiency.
Choice D rationale
Alcohol consumption during pregnancy can lead to Fetal Alcohol Spectrum Disorders (FASDs), characterized by a range of physical, developmental, and neurobehavioral abnormalities. While alcohol is teratogenic, it does not specifically cause neural tube defects; rather, it impacts overall fetal development, particularly central nervous system development.
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