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 B
Explanation
Choice A rationale
Fetal movement felt by the pregnant woman is a presumptive sign of pregnancy, indicating probable fetal presence, but not definitive evidence.
Choice B rationale
Fetal heart rate noted on ultrasound is a positive sign of pregnancy, providing objective evidence of fetal existence within the uterus.
Choice C rationale
A positive pregnancy test indicates probable pregnancy due to hormonal presence, but it is not a definitive confirmation without further clinical evidence.
Choice D rationale
Braxton Hicks contractions are considered probable signs of pregnancy, as they indicate uterine activity without confirming the presence of a fetus.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Calling for help and notifying the care provider ensures that expert medical assistance is available promptly for any emergency interventions required.
Choice B rationale
Getting help and preparing the operating room ensures readiness for an immediate cesarean section if fetal distress persists and the situation does not improve rapidly.
Choice C rationale
Starting Pitocin is inappropriate during fetal distress as it may further stress the fetus by increasing contraction frequency and intensity, potentially worsening the situation.
Choice D rationale
Inserting a Foley catheter does not address the immediate concern of fetal distress and would not provide immediate benefit in improving fetal heart rate.
Choice E rationale
Repeating uterine resuscitation measures (e.g., repositioning, oxygen, IV fluids) is essential, but if they are ineffective, additional interventions, such as preparing for possible surgical delivery, are needed.
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