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
While emergency cesarean birth preparation may be necessary in some cases, the primary focus should be on monitoring labor progression and the effects of oxytocin.
Choice B rationale
Monitoring the intensity, interval, and length of contractions is crucial in assessing the efficacy of oxytocin and ensuring the progress of labor while minimizing the risk of uterine hyperstimulation.
Choice C rationale
Checking the perineum for bulging is important in advanced labor stages but is not the primary focus when managing hypotonic dystocia and oxytocin administration.
Choice D rationale
Monitoring the client’s hourly blood pressure is important for overall health but is secondary to evaluating the contraction patterns and effectiveness of oxytocin in labor progression
Correct Answer is C
Explanation
Choice A rationale
Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.
Choice B rationale
Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.
Choice C rationale
Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.
Choice D rationale
While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.
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