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 should suspect a problem with the umbilical cord when she observes which of the following patterns?

Accelerations

Early decelerations

Late decelerations

Variable decelerations

Answer and Explanation

The Correct Answer is D

The correct answer is D. Variable decelerations.

A. Accelerations in the fetal heart rate are generally considered reassuring. Accelerations are an indication of fetal well-being and are often seen in response to fetal movement.

B. Early decelerations are typically associated with head compression during contractions and are considered a normal response to the pressure on the fetal head.

C. Late decelerations are indicative of uteroplacental insufficiency.

Late decelerations occur after the peak of the contraction and are associated with inadequate oxygenation to the fetus. This pattern raises concerns about the baby's well-being.

D. Variable decelerations are associated with umbilical cord compression.

Variable decelerations are abrupt decreases in the fetal heart rate that vary in duration, depth, and timing. They often coincide with contractions and suggest compression or occlusion of the umbilical cord.

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Correct Answer is A

Explanation

The correct answer is A. Slow-paced breathing

A. Slow-paced breathing is a nonpharmacological comfort measure that involves taking slow, deep breaths to promote relaxation and reduce anxiety. It can be an effective technique for managing pain during contractions.

B. Biofeedback involves the use of electronic monitoring to provide feedback about physiological processes, and it is not typically used as a primary nonpharmacological comfort measure for labor pain.

C. Self-hypnosis is a relaxation technique that involves guided imagery and focused concentration to promote relaxation and reduce pain. However, it may require some previous knowledge or practice, and in the context of this scenario, slow-paced breathing may be a more immediate and accessible option.

D. Acupuncture involves the insertion of needles into specific points on the body to stimulate energy flow. While acupuncture can be effective for pain management, it may not be readily available in all labor settings, and slow-paced breathing is a more universally applicable option.

A. Place a rolled towel beneath one of the client's hips. B. Apply internal upward pressure to the presenting part using two gloved fingers. C. Administer oxygen to the client via a nonrebreather mask at 10 L/min. D. Increase the infusion rate

Correct Answer is B

Explanation

Choice A Reason:

Placing a rolled towel beneath one of the client's hips may be helpful to tilt the client and alleviate pressure, but it is not the first action.

Choice B Reason:

Applying internal upward pressure to the presenting part using two gloved fingers is appropriate. This maneuver, known as "manual elevation of the presenting part," helps lift the presenting part off the prolapsed cord, preventing compression and maintaining blood flow to the fetus. This action should be performed while waiting for additional assistance and interventions.

Choice C Reason:

Administering oxygen is important for the well-being of the fetus, but the immediate focus is on relieving pressure on the umbilical cord.

Choice D Reason:

Increasing the infusion rate may be necessary later, but the immediate priority is to address the prolapsed cord and ensure fetal oxygenation.

4.A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse Include?

A. Place the shoulder harness in the slots above the newborn's shoulders.

B. Place the retainer clip at the level of the newborn's armpits.

C. Place the newborn at a 60° angle in the car seat.

D. Place the newborn in a blanket before securing them in the car seat.

Explanation

The correct answer is choice B

Choice A Reason:

Placing the shoulder harness in the slots above the newborn's shoulders is incorrect. The harness should be threaded through the slots at or below the baby's shoulders to provide proper protection.

Choice B Reason:

Placing the retainer clip at the level of the newborn's armpits is correct. This is a critical safety measure to ensure that the harness straps are positioned correctly on the newborn. Placing the retainer clip at the level of the armpits helps secure the harness straps over the baby's shoulders and prevents them from slipping off.

Choice C Reason:

Placing the newborn at a 60° angle in the car seat is not a standard recommendation. The car seat should be installed according to the manufacturer's instructions, and the baby should be placed in a semi-reclined position, typically at a 45° angle, to ensure proper support for the newborn's head and airway.

Choice D Reason:

Placing the newborn in a blanket before securing them in the car seat is not recommended. Extra padding, including bulky clothing or blankets, should not be placed under the harness straps as it can compromise the effectiveness of the restraint system. The baby should be dressed in thin layers, and if additional warmth is needed, a blanket can be placed over the baby after securing them in the car seat.

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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 should suspect a problem with the umbilical cord when she observes which of the following patterns?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

Correct Answer is A

Explanation

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagin

Correct Answer is B

Explanation

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