A nurse is preparing to measure the baseline fetal heart rate (FHR) on a client in labor.
Which of the following statements is NOT accurate regarding baseline fetal heart rates?
The baseline FHR is assessed over a 10-minute period.
The baseline FHR can be obtained via ultrasound or auscultation.
The baseline FHR can be obtained during contractions.
The baseline FHR is normal between 110-160 bpm.
The Correct Answer is A
Choice A rationale
Elevating the head reduces the risk of aspiration by preventing stomach contents, including gastric juices, from entering the lungs. This position is essential for infants with tracheoesophageal fistula due to the abnormal connection between the trachea and esophagus, which increases aspiration risk.
Choice B rationale
Facilitating food digestion is not the primary goal of this positioning. Gastric motility and digestion are unaffected by head elevation, making this rationale irrelevant to the question. Therefore, this is not the correct choice.
Choice C rationale
While head elevation can improve breathing by reducing diaphragm compression, the primary purpose in this context is to prevent aspiration. Lung expansion is a secondary benefit, but it is not the main reason for this position.
Choice D rationale
Reducing stomach pressure is not the key reason for elevating the head in this case. Although head elevation can minimize intra-abdominal pressure, this rationale does not address the critical concern of preventing aspiration in tracheoesophageal fistula. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Weighing an infant's diaper for output is a task suitable for unlicensed assistive personnel (UAP) because it involves data collection rather than clinical judgment or critical thinking. The results can be recorded and reported to the nurse for further assessment and interpretation.
Choice B rationale
Assessing a post-operative dressing requires clinical judgment to identify signs of infection, dehiscence, or other complications. This task is within the scope of a licensed nurse and should not be delegated to UAP to ensure patient safety.
Choice C rationale
Calculating the Morse Fall Scale involves understanding and interpreting risk factors, which requires critical thinking and clinical judgment. It is inappropriate for delegation to UAP, as they are not trained to analyze or interpret clinical data.
Choice D rationale
Performing an assessment of a child's developmental milestones requires knowledge of growth and development patterns, as well as clinical judgment to interpret findings. This task is outside the scope of UAP and must be performed by a licensed nurse.
Correct Answer is A
Explanation
Choice A rationale
Postpartum depression is more likely in individuals with a history of depression due to predisposing factors such as neurochemical imbalances and psychosocial stressors. Pregnancy and childbirth exacerbate these vulnerabilities through hormonal fluctuations, sleep deprivation, and new parenting stress. Early identification of at-risk populations is critical to prevent severe outcomes and promote maternal mental health.
Choice B rationale
Psychotic behavior is not a common feature of postpartum depression. It is more characteristic of postpartum psychosis, a rare and severe condition that requires immediate intervention. Postpartum depression primarily manifests as feelings of sadness, anxiety, and difficulty bonding with the infant, rather than psychotic symptoms like delusions or hallucinations.
Choice C rationale
Harming the infant is not the most common manifestation of postpartum depression. While intrusive thoughts may occur, the condition primarily presents with emotional symptoms such as hopelessness, guilt, and fatigue. Focused therapy can address these feelings and help prevent rare but severe outcomes involving harm.
Choice D rationale
Postpartum depression typically develops within 1–4 weeks after delivery, with symptoms often emerging gradually. The claim that it begins within 48 hours is inaccurate and more representative of the "baby blues," a transient and less severe condition. Accurate diagnosis involves monitoring symptom progression over time. .
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