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
Metal detectors at airport security checkpoints are considered safe and do not pose any risk of harm to the fetus.
Choice B rationale
Seat belts and shoulder restraints should always be used as they provide essential protection for both the mother and the fetus during travel.
Choice C rationale
Pregnant women are advised to walk around every hour during long periods of sitting to improve circulation and prevent blood clots, enhancing fetal health.
Choice D rationale
Prolonged sitting and crossing legs can impede circulation and increase the risk of venous thromboembolism, making it essential to avoid such practices.
Correct Answer is C
Explanation
Choice A rationale
Limited perception of bladder fullness can occur with epidural anesthesia, but it is not the most common or harmful complication. Patients should be monitored for urinary retention.
Choice B rationale
Severe afterbirth headache, or post-dural puncture headache, can result from epidural complications, but it is less common than hypotension.
Choice C rationale
Hypotension is the most common and potentially harmful complication of epidural anesthesia. It occurs due to sympathetic nerve blockade, leading to vasodilation and decreased cardiac output. Normal blood pressure ranges: systolic 90-120 mmHg, diastolic 60-80 mmHg.
Choice D rationale
Increased respiratory rate is not a common complication of epidural anesthesia. It is more likely related to anxiety or other factors and should be monitored accordingly.
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