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 B
Explanation
Choice A rationale
Notifying child protective services without further assessment may cause unnecessary distress and legal complications. The client's current alcohol use reduction efforts should be considered, and other interventions can be explored first.
Choice B rationale
Praising the client for reducing alcohol intake encourages positive behavior. Providing support and discussing ways to further decrease consumption promotes a collaborative approach to reducing alcohol exposure during pregnancy.
Choice C rationale
Disulfiram therapy is not suitable for pregnant clients due to potential risks. Instead, referral to an outpatient alcohol abuse program for counseling and support is more appropriate and safer for both mother and fetus.
Choice D rationale
Insisting on complete alcohol cessation without providing support may result in non-compliance. Drawing blood alcohol levels at each visit may cause anxiety and is not a practical approach for monitoring alcohol use in pregnancy.
Correct Answer is D
Explanation
Choice A rationale
Yogurt is not a significant source of folic acid, providing minimal contribution to the daily requirement needed during pregnancy.
Choice B rationale
Whole milk is not a substantial source of folic acid, contributing little to meeting the daily folic acid requirement for pregnant women.
Choice C rationale
Collard greens are rich in folic acid, but the client's dislike for green leafy vegetables makes them unsuitable in this context.
Choice D rationale
Strawberries are a good source of folic acid and can help meet the recommended daily intake for folic acid in pregnant women.
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