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 B
Explanation
Choice A rationale
Lanolin cream is used to treat or prevent sore, cracked nipples by providing a moisturizing barrier. It is not an effective measure for treating breast engorgement, which is caused by venous and lymphatic stasis and milk accumulation, leading to painful swelling. Treatment focuses on relief of swelling and efficient milk removal.
Choice B rationale
Encouraging the mother to wear a firm-fitting, supportive bra or apply breast binding provides compression to the breasts. This compression helps to inhibit milk production by mechanically interfering with milk removal and reducing local circulation, which alleviates the swelling and discomfort associated with engorgement.
Choice C rationale
Decreasing fluid intake to an extremely low level (<500 mL/24 hours) is ineffective and potentially detrimental to the mother's overall hydration status. Engorgement is a local breast issue involving fluid shifts and milk stasis, and systemic hydration levels do not directly resolve the breast swelling.
Choice D rationale
Discontinuing breastfeeding will worsen engorgement because the breasts will become fuller and the pressure will increase, leading to more discomfort. The appropriate management for engorgement is frequent and effective milk removal, typically through continued nursing or pumping, along with local comfort measures.
Correct Answer is B
Explanation
Choice A rationale
Stronger contractions are not a specific complication of breech presentation. Contraction strength is related to uterine action and response to oxytocin, not solely to fetal presentation. Breech presentation primarily poses risks related to the birthing process itself, such as cord prolapse and birth trauma.
Choice B rationale
In a breech presentation, the presenting part (buttocks or feet) is less effective than the head in filling the pelvic inlet, potentially leaving space for the umbilical cord to prolapse, especially upon rupture of membranes. Cord prolapse causes nonreassuring fetal signs such as sudden, severe variable decelerations or prolonged bradycardia due to cord compression and subsequent fetal hypoxia.
Choice C rationale
Precipitate labor is characterized by very rapid cervical dilation and fetal descent, usually occurring within three hours of labor onset. This is not directly caused by a breech presentation. The mechanism of labor in breech is often slower and more complicated due to the less efficient presenting part.
Choice D rationale
Cessation of contractions often indicates uterine fatigue or uterine inertia, which can occur in prolonged labor or with specific uterine conditions, but it is not a direct or common complication of breech presentation. Overstretching of the uterus is typically associated with polyhydramnios or multiple gestation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.