A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
Umbilical cord compression
Uteroplacental insufficiency
Fetal head compression
Material bradycardia
The Correct Answer is B
The correct answer is B. Uteroplacental insufficiency.
A. Umbilical cord compression is more commonly associated with variable decelerations, not late decelerations. Variable decelerations are characterized by abrupt decreases and increases in the fetal heart rate.
B. Late decelerations are indicative of uteroplacental insufficiency.
Uteroplacental insufficiency refers to a decrease in blood flow and oxygen supply from the mother to the fetus. Late decelerations occur after the peak of the contraction and may suggest inadequate oxygenation to the fetus.
C. Fetal head compression is associated with early decelerations, not late decelerations. Early decelerations typically coincide with the contractions and are considered a normal response to head compression during contractions.
D. Maternal bradycardia is not typically associated with late decelerations. Late decelerations are primarily related to issues with oxygenation and blood flow to the fetus.
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Related Questions
Correct Answer is A
Explanation
A. Correct. In rapidly progressing labor, applying gentle perineal pressure helps control the speed of delivery and can prevent or minimize perineal tearing or lacerations. It also helps to manage the delivery of the fetal head, especially in cases where the labor is very rapid which can cause neurologic damage (increased intracranial pressure and dural/subdural tearing).
B. Cutting the umbilical cord is not the priority in this situation. The focus should be on the immediate management of the delivery process and preventing complications related to perineal tearing.
C. Preventing the perineum from tearing: While preventing the perineum from tearing is important, it is not the immediate priority in the context of rapidly progressing labor. The primary focus should be on safely delivering the baby, which involves controlling the delivery of the fetal head to prevent complications.
D. Promoting the delivery of the placenta is a consideration for the third stage of labor, which follows the delivery of the baby. It is not the priority during the active phase of delivery.
Correct Answer is C
Explanation
The correct answer is C. Observe for crowning.
A. Applying fundal pressure is not indicated when the fetal head is at 3+ station. Fundal pressure is generally discouraged as it can increase the risk of fetal and maternal complications.
B. Preparing to administer oxytocin may be necessary later in labor but is not the immediate priority when the fetal head is still at 3+ station.
C. Observing for crowning is the correct action.
Crowning occurs when the widest part of the fetal head is visible at the vaginal opening during contractions. It is a sign that the baby is descending and the client is in the second stage of labor.
D. Observing for the presence of a nuchal cord is a valid consideration, but observing for crowning takes precedence at this stage of labor. Nuchal cords can be managed appropriately once the fetal head has descended further.
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