The nurse is evaluating the fetal monitor tracing of the patient who is in active labor.
Suddenly, the nurse sees the FHR drop from its baseline of 125 down to 80. The nurse repositions the mother, provides oxygen, increases intravenous fluids, and performs a vaginal exam.
The cervix has not changed.
Two minutes have passed, and the fetal heart rate remains in the 70s.
What additional nursing measures should the nurse take?
Call for help and notify the care provider.
Immediately get help and have the operating room ready.
Start Pitocin.
Insert a Foley catheter.
Repeat the uterine resuscitation.
Correct Answer : A,B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placental uterine insufficiency causes late decelerations, not early decelerations. Late decelerations indicate decreased placental perfusion and inadequate fetal oxygenation.
Choice B rationale
Umbilical cord compression leads to variable decelerations, characterized by abrupt decreases in fetal heart rate. Early decelerations are unrelated to cord compression.
Choice C rationale
Early decelerations are caused by head compression during contractions. This reflex response results in vagal stimulation and a uniform, gradual decrease in fetal heart rate, mirroring contractions.
Choice D rationale
Spontaneous rupture of membranes can influence labor progress but does not cause early decelerations. Early decelerations are primarily associated with head compression during contractions.
Correct Answer is A
Explanation
Choice A rationale
Fetal sleep cycles cause temporary decreased variability in FHR, typically lasting 20 minutes or less. FHR baseline remains normal. Normal FHR variability is 6-25 bpm.
Choice B rationale
Head compression during contractions leads to early decelerations in FHR, not decreased variability. Early decelerations are a normal response to pressure on the fetal head.
Choice C rationale
Fetal hypoxemia causes decreased variability but usually persists for longer than 20 minutes. It indicates compromised oxygen supply, requiring immediate intervention.
Choice D rationale
Umbilical cord compression leads to variable decelerations in FHR rather than decreased variability. These decelerations vary in onset, duration, and intensity.
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