A nurse is reviewing the electronic fetal monitor tracing of a client who has a prolapsed umbilical cord.
Which of the following fetal heart rate patterns indicates cord compression and hypoxemia?
Episodic accelerations
Fibrillation
Moderate tachycardia
Severe variable decelerations
The Correct Answer is D
The correct answer is choice D. Severe variable decelerations indicate cord compression and hypoxemia in a fetus with a prolapsed umbilical cord. Variable decelerations are abrupt decreases in fetal heart rate below the baseline, usually associated with uterine contractions. Severe variable decelerations are defined as having a nadir of less than 70 beats per minute or lasting longer than 60 seconds.
Choice A is wrong because episodic accelerations are transient increases in fetal heart rate above the baseline, usually indicating fetal well-being.
Choice B is wrong because fibrillation is an irregular and rapid contraction of the atria of the heart, which is not a normal fetal heart rate pattern.
Choice C is wrong because moderate tachycardia is a slightly elevated fetal heart rate above the normal range of 110 to 160 beats per minute, which may be caused by maternal fever, fetal infection, fetal anemia, or fetal hypoxia.
However, moderate tachycardia alone does not indicate cord compression and hypoxemia.
The normal range of fetal heart rate is 110 to 160 beats per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The correct answer is choices A, B and C. These are the risk factors for umbilical cord prolapse that the nurse should include in the teaching.Umbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus.It can cause fetal hypoxia and distress by occluding or compressing the blood flow to the fetus.
Choice A is correct because premature rupture of membranes, especially when the presenting part of the fetus is high in the pelvis, can allow the cord to slip down into the cervix and vagina.
Choice B is correct because breech presentation, such as a footling breech, can make it easy for the cord to slip between and past the fetal feet and into the pelvis.
Choice C is correct because polyhydramnios, or excessive amniotic fluid around the fetus, can create more space for the cord to move and prolapse.
Choice D is wrong because post-term pregnancy is not a risk factor for umbilical cord prolapse.Post-term pregnancy can cause other complications such as fetal macrosomia, placental insufficiency and meconium aspiration.
Choice E is wrong because multiple gestation is not a risk factor for umbilical cord prolapse.Multiple gestation can cause other complications such as preterm labor, preeclampsia and fetal growth restriction.
Correct Answer is A
Explanation
The correct answer is choice A. Elevate the presenting part with a sterile gloved hand.This intervention helps to relieve cord compression until delivery by preventing the fetus from pushing down on the cord.The umbilical cord is the lifeline of the fetus and any compression can cause fetal hypoxemia and distress.
Choice B is wrong because pushing the cord back into the vagina with gentle pressure can cause more damage to the cord and increase the risk of infection.
Choice C is wrong because clamping and cutting the cord as quickly as possible will cut off the fetal blood supply and oxygenation.
Choice D is wrong because wrapping the cord loosely around the fetal neck can cause strangulation and compromise fetal circulation.
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