The nurse is assessing a fetus via ultrasound after a 15 beat/minute deceleration of the fetal heart rate below the baseline lasting 15 seconds.
Based on the information in the image, what intervention would the nurse perform?
Increase intravenous fluids.
Place the client's legs knee to chest.
Assist the client to change positions.
Administer oxygen via face mask.
The Correct Answer is C
Choice A rationale
Increasing intravenous fluids (IVFs) addresses hypovolemia which can be a cause of late decelerations due to reduced uteroplacental perfusion, but the provided scenario describes an isolated deceleration lasting only 15 seconds, which is classified as a non-reassuring variable deceleration if the drop is ≥ 15 beats/minute. A variable deceleration is caused by umbilical cord compression, which is best managed by position change.
Choice B rationale
Placing the client's legs knee to chest (or deep Trendelenburg) is a specific intervention reserved for a diagnosed umbilical cord prolapse to relieve pressure on the prolapsed cord until an emergency delivery can occur. The brief, isolated nature of the deceleration described does not indicate a frank cord prolapse, and this extreme position is not the first-line intervention for a typical variable deceleration.
Choice C rationale
Assisting the client to change positions (e.g., from supine to lateral, or left to right lateral) is the most effective initial intervention for variable decelerations. These decelerations are caused by umbilical cord compression, and changing the maternal position often relieves the pressure on the cord, thus restoring normal fetal circulation and promptly resolving the transient drop in the fetal heart rate.
Choice D rationale
Administering oxygen via face mask addresses potential maternal hypoxemia that could lead to fetal hypoxia and subsequent late decelerations, or prolonged decelerations that compromise fetal oxygenation. For a brief, isolated variable deceleration that quickly resolves (as implied by the short duration), oxygen is not the immediate or primary intervention; position change is more critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A second-degree perineal laceration involves the vaginal mucosa, perineal skin, and the perineal muscles, but not the anal sphincter. The proximity of the repair to the urethra and the potential for perineal edema and pain can inhibit the voiding reflex and cause urethral spasm, leading to temporary difficulty in spontaneously emptying the bladder post-delivery.
Choice B rationale
The onset of milk production (lactogenesis II) is primarily controlled by the rapid drop in progesterone levels following the expulsion of the placenta and subsequent increase in prolactin release. A second-degree perineal laceration and repair, which is a localized soft tissue injury, has no direct physiological impact on the endocrine cascade responsible for initiating lactation.
Choice C rationale
Maladaptive bonding is a complex psychological issue influenced by factors like maternal mental health, pain, fatigue, and social support. While a painful laceration can contribute to discomfort and stress, a second-degree tear itself is a physical injury and does not directly cause an abnormal bonding process, which is a behavioral and emotional phenomenon.
Choice D rationale
Posterior vaginal varicosities (enlarged veins) are caused by the increased venous pressure and blood volume associated with pregnancy, and potential pressure from the descending fetal head during labor. A second-degree perineal laceration and its repair are the result of the birthing process and do not cause pre-existing vascular conditions like varicosities.
Correct Answer is A
Explanation
Choice A rationale
This response validates the client's feelings ("A woman can feel upset.”.) and employs an open-ended question ("Can you tell me more.”.) to encourage further therapeutic communication. This supportive approach recognizes the client's grief over the loss of the desired birth experience and facilitates the emotional processing necessary for bonding.
Choice B rationale
Minimizing the client's current emotional state by suggesting it will improve later is non-therapeutic, as it invalidates her present feelings and can create a communication barrier. Bonding is a process, and initial upset can hinder it, but simply waiting for improvement isn't the best response.
Choice C rationale
Suggesting a diagnosis of postpartum depression (PPD) prematurely is inappropriate and anxiety-provoking. The "baby blues," which typically include emotional lability and crying on the third day, are a normal physiological and psychological adjustment due to hormonal shifts and the reality of parenthood.
Choice D rationale
Asking a rhetorical, even accusatory question about prenatal discussions invalidates the client's feelings by suggesting she should have been prepared or better informed. It shifts the focus away from her current distress, failing to provide the needed emotional support and acceptance.
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