A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
Accelerations.
Late decelerations.
Variable decelerations.
Early decelerations.
The Correct Answer is C
Choice A. Accelerations are normal responses that indicate the fetus is healthy and active. Accelerations occur when the fetal heart rate increases in response to stimuli. •
Choice B. Late decelerations are nonreassuring patterns that indicate fetal hypoxia due to placental insufficiency. Late decelerations occur when the placental blood flow decreases due to uterine contractions during labor, causing the fetal heart rate to decrease. •
Choice C. Variable decelerations are nonreassuring patterns that indicate fetal hypoxia due to umbilical cord compression. Variable decelerations occur when the umbilical cord is trapped by the cervical opening or the fetal body part, twisted, or knotted, causing the fetal oxygen supply to be impaired and the fetal heart rate to drop sharply. •
Choice D. Early decelerations are reassuring patterns that indicate a neural reflex due to fetal head compression. Early decelerations occur when the fetal head is compressed by uterine contractions during labor, causing the parasympathetic nervous system to be stimulated and the heart rate to decrease. The correct answer is C. Variable decelerations are the most common pattern that indicates a problem with the umbilical cord and requires urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nalbuphine (Nubain):Nalbuphine is an opioid agonist-antagonist, which can be used to treat moderate to severe pain. However, it is not specifically used to reverse the effects of fentanyl. Administering Nalbuphine could potentially complicate the situation by introducing another opioid into the system.
B. Naloxone (Narcan):Naloxone is an opioid antagonist that rapidly reverses the effects of opioids like fentanyl. It is the standard treatment for opioid overdose and can quickly restore normal respiration in a person whose breathing has slowed or stopped due to opioid use. This makes it the most appropriate drug to have readily available in this scenario.
C. Butorphanol (Stadol):Butorphanol is another opioid agonist-antagonist used for pain relief. Similar to Nalbuphine, it is not used to reverse opioid effects and could complicate the patient's condition by adding another opioid to the system.
D. Promethazine (Phenergan):Promethazine is an antihistamine used to treat nausea, vomiting, and allergies. It does not have any properties that would counteract the effects of fentanyl. Therefore, it would not be useful in reversing opioid-induced respiratory depression.
Correct Answer is B
Explanation
Choice A reason:
Lochial color changes from rubra to alba in the early postpartum period is a normal event. Lochia is the vaginal discharge that occurs after childbirth, and it progresses from bright red (rubra) to pink or brownish (serosa) to whitish-yellow (alba) as the days pass.
Choice B reason:
Extreme hunger and thirst in the early postpartum period may indicate abnormal blood sugar levels and can be a sign of gestational diabetes or other metabolic disorders. It requires further evaluation and monitoring by healthcare providers.
Choice C reason:
Diuresis (increased urination) and diaphoresis (increased sweating) are normal events in the early postpartum period. After childbirth, the body eliminates excess fluid that was retained during pregnancy, leading to increased urination and sweating.
Choice D reason:
Flatulence (passing gas) and constipation can be normal events in the early postpartum period due to the body recovering from the effects of labor, changes in diet, and the use of pain medications during childbirth.
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