The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?
Variable decelerations.
Late decelerations.
No decelerations.
Early decelerations.
The Correct Answer is B
Choice A rationale
Variable decelerations are abrupt decreases in fetal heart rate, unrelated to contractions and typically caused by umbilical cord compression. The described pattern does not match these characteristics.
Choice B rationale
Late decelerations occur when there is a gradual decrease in fetal heart rate starting after the contraction begins and returning to baseline after the contraction ends, often indicating utero-placental insufficiency.
Choice C rationale
No decelerations are present when there are no decreases in fetal heart rate. The scenario described includes a specific pattern of decelerations, making this choice incorrect.
Choice D rationale
Early decelerations are a gradual decrease in fetal heart rate that mirrors the contraction pattern, often caused by head compression during contractions. The pattern described does not fit early decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Caput succedaneum is a benign swelling of the soft tissues of the scalp that crosses suture lines and does not require drainage.
Choice B rationale
Cephalhematoma is a collection of blood between the skull and periosteum that does not cross suture lines; it may contribute to jaundice as it is reabsorbed by the body.
Choice C rationale
While cephalhematoma usually resolves without intervention, it is important to monitor for potential complications, including jaundice, due to the breakdown of red blood cells.
Choice D rationale
Caput succedaneum typically resolves on its own without intervention, as the fluid is gradually absorbed by the body over time.
Correct Answer is B
Explanation
Choice A rationale
Starting oxytocin infusion immediately may cause uterine hyperstimulation in clients who have already responded to misoprostol. Close monitoring and spacing out uterotonic agents help prevent adverse effects like uterine tachysystole and fetal distress.
Choice B rationale
Beginning oxytocin 4 hours after misoprostol ensures sufficient time for cervical ripening and reduces the risk of uterine hyperstimulation. This allows for safer labor induction and better outcomes for both mother and fetus.
Choice C rationale
Ambulating the client after misoprostol administration is generally safe but doesn't address the need for controlled uterotonic administration. Monitoring and timing of further uterotonics are crucial to avoid adverse effects and ensure safe induction.
Choice D rationale
Administering misoprostol every 2 hours is not recommended due to the risk of uterine hyperstimulation. It’s important to follow safe dosing intervals to reduce the risk of complications such as uterine tachysystole and fetal compromise.
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