The nurse is caring for a client in labor. Assessment findings: The fetal heart rate (FHR) baseline is 120 bpm The FHR begins slowing as the contraction starts, and is back to baseline at the end of the contraction There is moderate variability of the FHR Which periodic change will the nurse document in the electronic health record?

Late

Early

Acceleration

Variable

Answer and Explanation

The Correct Answer is B

A.   Late decelerations typically start after the contraction has reached its peak and return to baseline after the contraction ends, not during the contraction.
B.   Early decelerations coincide with the contraction and return to baseline by the end of the contraction. They are typically considered benign and related to head compression.
C.   Accelerations are brief increases in the FHR above the baseline and are usually associated with fetal movement.
D.   Variable decelerations are abrupt decreases in the FHR, often unrelated to contractions, and have an erratic pattern.

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Correct Answer is ["A","B"]

Explanation

A. Effacement refers to the thinning of the cervix, making it easier for the cervix to dilate during labor.
B. Effacement also involves the shortening of the cervix, contributing to the progressive dilation during labor.

C. Engagement refers to the descent of the fetal head into the pelvic inlet, not a part of effacement.
D. Effacement does not involve the cervix becoming wider; dilation refers to the opening of the cervix.
E. Effacement does not involve the cervix becoming lower; descent of the presenting part is associated with engagement.

A. Suggest catheterizing her this time to prevent the possibility of fainting B. Ask the client to lie back down and get her a bedpan C. Assist the client to the bathroom D. Have the client sit dangling her legs over the side of the bed for 5 minutes

Correct Answer is C

Explanation

A. Catheterization may not be necessary at this time and can be uncomfortable for the client.

B. Using a bedpan may not be the most comfortable option for the client, who likely wants to ambulate.
C. Assisting the client to the bathroom is the best response to ensure her safety and prevent falls.

D. Dangling the legs over the side of the bed is not necessary in this situation and may not address the client's need to use the bathroom.

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Naxlex Comprehensive Predictor Exams

The nurse assesses a laboring client's cervix and states it is 6 cm dilated and 70% effaced. The client asks what it means to be effaced. Which descriptions will the nurse include when responding to the client? Select all that apply.

Correct Answer is ["A","B"]

Explanation

Correct Answer is C

Explanation

The nurse is caring for a client in labor and discovers late decelerations of the fetal heart rate. What does the nurse know as the reason for this type of deceleration?

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The nurse is assessing the fetal monitoring tracing below. Which type of fetal heart rate variability is pictured here in the top tracing?