The nurse caring for a client in labor observes the external fetal monitor tracing showing that there are accelerations with moderate variability.
Which of the following actions is most appropriate?
Document the findings and tell the mother that the monitor indicates fetal well-being.
Call the midwife or doctor right away to tell them.
Take the mother’s vital signs and tell her that bed rest is required to conserve oxygen.
Reposition the mother and check the monitor for changes in the fetal tracing.
The Correct Answer is A
Choice A rationale
Accelerations with moderate variability indicate fetal well-being and responsiveness to the uterine environment, requiring documentation of normal findings and reassurance to the mother.
Choice B rationale
There is no need to immediately call the midwife or doctor, as accelerations with moderate variability are positive indicators of fetal health and do not suggest any issues.
Choice C rationale
Taking maternal vital signs and advising bed rest is unnecessary because the observed accelerations and variability show that the fetus is not experiencing distress, negating the need for such interventions.
Choice D rationale
Repositioning the mother and checking the monitor for changes is unnecessary, given that accelerations with moderate variability already indicate a well-oxygenated and responsive fetus, not requiring any adjustments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Testing the fluid with nitrazine paper can confirm membrane rupture but is not the first priority. Assessing the fetal heart rate is crucial to ensure fetal well-being immediately after membrane rupture.
Choice B rationale
Documenting the time of rupture is important for clinical records but is not the first priority. Immediate assessment of fetal status takes precedence to detect any distress.
Choice C rationale
Monitoring the fetal heart rate and pattern immediately after membrane rupture is essential to ensure the fetus is not in distress. It helps detect any complications like cord prolapse.
Choice D rationale
Notifying the physician or midwife is necessary but not the first priority. Ensuring fetal well-being through heart rate monitoring is the immediate concern following membrane rupture.
Correct Answer is C
Explanation
Choice A rationale
Uterine contractions (powers) are essential for cervical dilation and fetal descent. They are involuntary smooth muscle contractions regulated by oxytocin and prostaglandins.
Choice B rationale
The fetus (passenger) significantly influences labor progression. Fetal size, position, and presentation affect the ease of passage through the birth canal.
Choice C rationale
Pressure is not considered one of the five Ps affecting labor and birth. The five Ps are powers, passenger, passageway, position, and psychological response.
Choice D rationale
The birth canal (passageway) includes the bony pelvis and soft tissues, which must adapt to allow the fetus to pass through during labor.
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