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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Fetal lung maturity is the primary indication for performing an amniocentesis in a client at or near term who is at risk for preterm delivery. The procedure allows analysis of amniotic fluid for lecithin-sphingomyelin (L/S) ratio and presence of phosphatidylglycerol (PG), which are markers of pulmonary maturity. This information helps the provider determine whether it is safe to deliver the fetus or if interventions are needed to reduce the risk of neonatal respiratory distress.

B. Amniocentesis is not used to determine fetal size or weight. These assessments are typically done through ultrasound measurements, not amniotic fluid analysis.

C. Fetal glucose levels are not routinely measured via amniocentesis. Maternal blood glucose control and fetal well-being are monitored through maternal labs and noninvasive fetal assessments rather than direct glucose measurement in amniotic fluid.

D. Genetic abnormalities are typically assessed via amniocentesis earlier in pregnancy (15–20 weeks). At 36 weeks, the focus shifts from genetic testing to evaluating lung maturity and readiness for safe delivery, not chromosomal analysis.

A. A localized area of breast tenderness B. Moderate amount of dark red, foul smelling lochia C. Hematuria D. Cramping with breastfeeding

Correct Answer is B

Explanation

A. A localized area of breast tenderness is more commonly associated with mastitis or breast engorgement. While these are postpartum complications, they are not indicative of uterine infection or endometritis and do not typically require evaluation for uterine infection.
B. Moderate, dark red, foul-smelling lochia is a hallmark sign of endometritis, an infection of the uterine lining (usually occurring within the first 2–10 days postpartum). This symptom indicates the presence of bacterial infection, often accompanied by fever, uterine tenderness, and malaise. Foul-smelling lochia occurs due to bacterial proliferation and breakdown of blood and tissue in the uterus, making further evaluation and prompt treatment necessary to prevent sepsis.
C. Hematuria (blood in the urine) suggests a urinary tract issue such as infection, trauma, or catheter-related irritation. It does not indicate endometritis, as the infection is localized to the uterine lining, not the urinary tract.
D. Cramping with breastfeeding, also known as afterpains, is a normal postpartum occurrence due to oxytocin-induced uterine contractions. While it can cause discomfort, it is expected and does not signal infection.

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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?

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Naxlex Comprehensive Predictor Exams

A 36 weeks gestation client at risk for preterm labor presents to the clinic. The nurse understands the indication to perform an amniocentesis at this time is to assess for what?

Correct Answer is A

Explanation

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?

Correct Answer is B

Explanation

A breastfeeding mother is being educated on a safe method to remove her breast from her baby's mouth. Which intervention is most appropriate?

While working with the pregnant client in her first trimester, what information does the nurse provide regarding when chorionic villus sampling (CVS) can be performed (in weeks of gestation)?

A laboring woman has received butorphanol intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of butorphanol on the neonate?

What is the most common reason for late postpartum hemorrhage (PPH)?

A fetal monitor shows variable decelerations. The nurse understands this is most often caused by:

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

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 observes early decelerations. The client is 9/100% / +3. Which intervention is most appropriate at this time?