The nurse is assuming care of a gravida 1, para 0 in active labor.
The off-going nurse tells you that the fetal monitor has been showing a fetal heart rate baseline of 140.
Below is the strip you see when you walk into her room.
What interventions are most appropriate at this time?
Document the findings as minimal variability with late decelerations. Provide intravenous fluid, Oxygen, reposition, and notify the provider.
Document the findings as moderate variability with early decelerations. Anticipate delivery soon.
Document the findings as moderate variability with variable decelerations. Change the patient's position first, then provide intravenous fluids and Oxygen.
Document the findings as minimal variability and accelerations. Continue to monitor.
The Correct Answer is A
Choice A rationale
The fetal heart rate (FHR) strip shows minimal variability (amplitude changes of 5 beats per minute or less), indicating potential fetal hypoxia or metabolic acidemia. Late decelerations are present, characterized by a gradual decrease in FHR beginning after the peak of the contraction and returning to baseline after the contraction ends, indicating uteroplacental insufficiency. This pattern is non-reassuring, requiring immediate intrauterine resuscitation measures (fluids, oxygen, repositioning) and provider notification. —.
Choice B rationale
Moderate variability would show an amplitude range of 6 to 25 beats per minute, which is not seen on this strip, classifying it as minimal. Early decelerations mirror the contraction, starting before or at the beginning of the contraction and returning to baseline by the end, typically indicating head compression and being benign, unlike the late decelerations visible. —.
Choice C rationale
Moderate variability is defined as an amplitude range of 6 to 25 beats per minute, which is absent here. Variable decelerations are an abrupt decrease in FHR, often U, V, or W-shaped, and vary in timing relative to contractions, reflecting cord compression. This strip shows late decelerations which are gradual and signify a more concerning issue of uteroplacental insufficiency. —.
Choice D rationale
The strip shows minimal variability (amplitude ≤ 5 bpm), indicating potential compromise, so continued monitoring alone is insufficient and potentially dangerous. Accelerations are abrupt increases in FHR above the baseline (at least 15 bpm for at least 15 seconds, or 10 × 10 for preterm), which are reassuring and not seen here. The presence of late decelerations necessitates immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A uterine hematoma typically presents with unrelenting pain and may cause signs of hypovolemic shock, which would be evidenced by tachycardia and hypotension, not necessarily a displaced, high fundus as a primary sign. While a Complete Blood Count (CBC) can detect associated anemia (normal hemoglobin is 12-16 g/dL), the immediate priority is addressing the fundus's position.
Choice B rationale
A full or distended urinary bladder pushes the uterus superiorly and laterally, commonly to the right side due to anatomical arrangement, causing it to be palpable above the expected level. This displacement inhibits proper uterine contraction and increases the risk of postpartum hemorrhage. The most appropriate initial intervention is to have the woman void or catheterize her, then reassess the fundus's position and tone.
Choice C rationale
While prolonged positioning can influence physical findings, the bladder's mechanical displacement of the uterus is a more common and clinically significant cause of a fundus displaced high and to the side in the immediate postpartum period. Simply changing position will not resolve the underlying issue of bladder distension, which compromises uterine hemostasis and must be addressed immediately.
Choice D rationale
While the health care provider must be informed of abnormal findings, contacting them is not the first action when a correctable physiological cause is highly suspected. The nurse should first attempt the least invasive intervention, which is addressing the likely full bladder, a common cause of this finding, and then reassess before escalating care. —.
Correct Answer is D
Explanation
Choice A rationale
Drying the newborn with a clean towel immediately after birth prevents heat loss primarily through evaporation. Evaporation occurs when water on the skin converts to vapor, which requires heat energy taken from the body surface. Removing the amniotic fluid and moisture eliminates the substrate for this specific form of heat loss, therefore maintaining the newborn's core temperature.
Choice B rationale
Placing the newborn skin-to-skin with the mother minimizes heat loss through conduction and radiation, while providing an external heat source. Conduction is direct heat transfer, which is minimized by placing the newborn on the warm maternal skin. Radiation is minimized by placing the infant close to the mother's body, which radiates heat back to the infant.
Choice C rationale
Keeping the bassinet away from windows or doors minimizes heat loss through convection and radiation. Convection is heat transfer by air currents, and drafts near windows increase this loss. Radiation is heat transfer to nearby cold objects, which is mitigated by avoiding placement next to cold glass. This primarily addresses air movement and cold surfaces.
Choice D rationale
Conduction is the transfer of heat from the newborn to a colder surface through direct contact. Using a warmed scale (or covering a cold surface with a warmed blanket) ensures that the object the infant is placed on for weighing is not significantly colder than the infant's skin, thereby preventing the rapid loss of thermal energy through this conductive mechanism.
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