During labor a fetus displays an average fetal heart rate (FHR) of 135 beats per minute over a 10-minute period with moderate variability, accelerations are present, and no decelerations are noted by the nurse. Which statement best describes the status of this fetus?
The fetus is hypoxic
The fetus has tachycardia
The fetus has bradycardia
Normal acid-base balance, no intervention is needed
The Correct Answer is D
A. Fetal hypoxia is typically indicated by abnormal FHR patterns, such as late decelerations, decreased or absent variability, bradycardia, or prolonged decelerations. In this scenario, the FHR shows a normal baseline, moderate variability, and accelerations, all of which suggest adequate oxygenation and fetal well-being.
B. Tachycardia is defined as a baseline FHR greater than 160 beats per minute. Causes of fetal tachycardia can include maternal fever, infection, medications, or fetal hypoxia, but this fetus has a baseline of 135 bpm, which is within the normal range of 110–160 bpm, so tachycardia is not present.
C. Bradycardia is defined as a baseline FHR less than 110 beats per minute. Causes of bradycardia can include prolonged cord compression, maternal hypotension, or congenital heart conditions, but this fetus has a baseline of 135 bpm, ruling out bradycardia.
D. This fetus exhibits a reassuring FHR pattern characterized by a normal baseline indicating adequate cardiac function, moderate variability reflecting an intact autonomic nervous system and good oxygenation, presence of accelerations demonstrating a responsive, well-oxygenated fetus, and absence of decelerations, indicating there is no evidence of uteroplacental compromise or cord compression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chorionic villus sampling (CVS) is typically performed between 10 and 13 weeks of gestation. It involves obtaining a small sample of placental tissue (chorionic villi) to test for chromosomal abnormalities, genetic disorders, and certain metabolic conditions. Performing the procedure within this timeframe allows for early detection of fetal abnormalities, which gives the parents more options for pregnancy management.
B. By 18 weeks of gestation, CVS is no longer indicated, as amniocentesis becomes the preferred procedure for prenatal genetic testing at mid-pregnancy. Performing CVS this late would increase the risk of complications without providing additional benefit.
C. At 6 weeks, the placenta is not sufficiently developed to obtain an adequate sample of chorionic villi. Attempting CVS this early carries a higher risk of procedure failure and complications, including miscarriage.
D. At 4 weeks, the embryo is too small and placental development is insufficient for CVS. Genetic testing is not feasible at this stage, and attempting it would be unsafe.
Correct Answer is B
Explanation
A. Betamethasone is a corticosteroid given to enhance fetal lung maturity, typically when preterm birth is anticipated (<34–37 weeks). At 38 weeks gestation, the fetus is term, so corticosteroids are not indicated.
B. Hydralazine is an antihypertensive medication used to treat severe hypertension in pregnancy (systolic ≥160 mm Hg or diastolic ≥110 mm Hg). This client’s BP is 170/112 mm Hg, which meets criteria for immediate pharmacologic intervention to prevent maternal complications such as stroke, eclampsia, or organ damage. Therefore, the nurse should anticipate an order for hydralazine (or another antihypertensive like labetalol or nifedipine) to lower blood pressure safely.
C. Dexamethasone is also a corticosteroid used to promote fetal lung development and is not indicated at term gestation (38 weeks) for this client.
D. Lovenox (enoxaparin) is an anticoagulant used for thromboembolism prevention. While some pregnant clients may require anticoagulation, this client’s primary acute concern is severe hypertension, not clotting risk, making Lovenox inappropriate as the first intervention.
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