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The patient is having fetal heart rate decelerations. An amnioinfusion has been ordered for the patient to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is:
Select one:

Late decelerations.

Moderate decelerations.

Variable decelerations.

Early decelerations.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Late decelerations. This is an incorrect answer that refers to a diﬀerent type of fetal heart rate patern that indicates uteroplacental insufficiency, which can reduce blood ﬂow and oxygen delivery to the fetus. Late decelerations are characterized by gradual decreases in fetal heart rate that begin after the peak of uterine contractions and return to baseline after the end of contractions. Amnioinfusion is not eﬀective for late decelerations, as it does not address the underlying cause of uteroplacental insufficiency, which may be due to maternal hypertension, diabetes, preeclampsia, or placental abruption.

Choice B Reason: Moderate decelerations. This is an incorrect answer that refers to a non-existent type of fetal heart rate patern, as there is no such term as moderate decelerations. The term moderate refers to the category of fetal heart rate variability, which is a measure of the ﬂuctuations in fetal heart rate around the baseline. Moderate variability indicates normal fetal oxygenation and well-being, while absent or minimal variability indicates fetal hypoxia or distress.

Choice C Reason: Variable decelerations. This is because variable decelerations are a type of fetal heart rate patern that indicates cord compression, which can reduce blood ﬂow and oxygen delivery to the fetus. Variable decelerations are characterized by abrupt decreases in fetal heart rate that vary in onset, depth, and duration, and do not have a consistent relationship with uterine contractions. Amnioinfusion is a procedure that involves infusing saline or lactated Ringer's solution into the amniotic cavity through a transcervical catheter, which can relieve cord compression by increasing the volume of amniotic ﬂuid and cushioning the cord. Amnioinfusion can improve fetal oxygenation and reduce variable decelerations.

Choice D Reason: Early decelerations. This is an incorrect answer that refers to a diﬀerent type of fetal heart rate patern that indicates head compression, which can stimulate the vagus nerve and slow down the fetal heart rate. Early decelerations are characterized by gradual decreases in fetal heart rate that begin with the onset of uterine contractions and return to baseline with the end of contractions. Early decelerations are benign and do not require intervention, as they reﬂect normal fetal head descent and progress of labor. Amnioinfusion is not indicated for early decelerations, as it does not aﬀect head compression or vagal stimulation.

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Correct Answer is B

Explanation

Choice A Reason: The cheek of the newborn is touched, and the newborn turns toward the side that was touched. This is an incorrect answer that describes a diﬀerent reﬂex called the rooting reﬂex. The rooting reﬂex is a feeding reﬂex that helps the newborn locate the nipple and initiate sucking. The rooting reﬂex is elicited by stroking the cheek or corner of the mouth of the newborn, which causes them to turn their head and open their mouth toward the stimulus.

Choice B Reason: The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together. This is because this response describes the Moro reﬂex, which is a primitive reﬂex that is present at birth and disappears by 3 to 6 months of age. The Moro reﬂex is elicited by simulating a falling sensation or a loud noise, which triggers a fear response in the newborn. The Moro reﬂex consists of four phases: extension, abduction, adduction, and crying.

Choice C Reason: The newborn is supine and their head is turned to one side, then the arm on that same side extends. This is an incorrect answer that refers to another reﬂex called the tonic neck reﬂex. The tonic neck reﬂex is a postural reﬂex that helps prepare the newborn for voluntary reaching. The tonic neck reﬂex is elicited by placing the newborn in a supine position and turning their head to one side, which causes them to assume a "fencing" posture with one arm extended and one arm ﬂexed.

Choice D Reason: The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward. This is an incorrect answer that indicates a diﬀerent reﬂex called the Babinski reﬂex. The Babinski reﬂex is a neurological reﬂex that tests for spinal cord integrity. The Babinski reﬂex is elicited by stroking the lateral aspect of the sole of the foot from heel to toe, which causes the big toe to dorsiﬂex and the other toes to fan out.

A. "You would have seen more symptoms if you had been looking more closely at your baby." B. "A newborn's immune system isn't mature, so symptoms are subtle and can be hard to recognize." C. "A high fever will always be present in sick newborns, including your baby." D. "A mother's immunity usually protects the infant from illness, but not in this case."

Correct Answer is B

Explanation

Choice A Reason: "You would have seen more symptoms if you had been looking more closely at your baby." This is an inappropriate response that blames the parents for missing the signs of sepsis and does not explain the Reason for the subtle symptoms.

Choice B Reason: "A newborn's immune system isn't mature, so symptoms are subtle and can be hard to recognize." This is an appropriate response that educates the parents about the immunological basis of sepsis in newborns and reassures them that they are not at fault for not noticing the symptoms.

Choice C Reason: "A high fever will always be present in sick newborns, including your baby." This is an incorrect response that contradicts the fact that newborns may not develop fever in response to infection due to their immature immune systems.

Choice D Reason: "A mother's immunity usually protects the infant from illness, but not in this case." This is an inaccurate response that implies that the mother failed to provide adequate immunity to her baby and does not address the question of why the baby did not seem very ill.

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Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see? Select one:

Correct Answer is B

Explanation

The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill. The best response of the nurse is: Select one:

Correct Answer is B

Explanation

The client at 42 weeks' pregnancy is admited for induction of her labor. Which statement indicates that she understands the Reasons for the induction? Select one:

A client has been diagnosed with postpartum psychosis. Which of the following actions should the nurse take? Select one:

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in: Select one:

The nurse administers vitamin K intramuscularly as prophylaxis to the newborn based on which of the following rationales? Select one:

Which of the following would be essential to implement to prevent late postpartum hemorrhage? Select one:

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? Select one:

Obstetrical risks to consider for a pregnant teenager would be all of the following, EXCEPT: Select one:

The primary factor that diﬀerentiates eclampsia from preeclampsia is: Select one: