A nurse is walking by a client's room and can hear the fetal heart rate dropping.
The nurse observes the heartbeat and interprets the monitor strip as indicating which of the following?

Uteroplacental insufficiency.

Umbilical cord compression.

Maternal bradycardia.

Fetal head compression.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Uteroplacental insufficiency typically results in late decelerations, not a sudden drop in fetal heart rate, which is more commonly caused by umbilical cord compression.

Choice B rationale

Umbilical cord compression can cause variable decelerations, which are characterized by a sudden drop in fetal heart rate. This occurs due to the umbilical cord being compressed, leading to decreased blood flow and oxygen to the fetus.

Choice C rationale

Maternal bradycardia refers to a slow maternal heart rate and does not directly cause changes in the fetal heart rate pattern.

Choice D rationale

Fetal head compression typically causes early decelerations, which are gradual decreases in fetal heart rate that occur with contractions and are usually benign.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Indicated:

B. Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.

D. Maintain an eye mask over the newborn's eyes.

E. Reposition the newborn every 2 hours.

F. Report sunken fontanels to the provider.

Contraindicated:

A. Apply lotion to the skin every 4 hours.

C. Newborn feedings should be every 8 hours.

A. Blue coloring of the hands and feet in an 8-hour-old newborn. B. Small raised pearly spots on the newborn's nose. C. Apical heart rate of 140 bpm. D. Nasal flaring and grunting.

Correct Answer is D

Explanation

Choice A rationale

Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.

Choice B rationale

Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.

Choice C rationale

An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.

Choice D rationale

Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.

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A nurse is walking by a client's room and can hear the fetal heart rate dropping.The nurse observes the heartbeat and interprets the monitor strip as indicating which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn with hyperbilirubinemia and is being treated with phototherapy. For each of the following nursing actions, specify if it is indicated or contraindicated with phototherapy treatment.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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Correct Answer is D

Explanation

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A nurse is walking by a client's room and can hear the fetal heart rate dropping.
The nurse observes the heartbeat and interprets the monitor strip as indicating which of the following?