The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate?

The fetus is in distress

The mother is in severe pain

Uteroplacental insufficiency

A well-oxygenated fetus

Answer and Explanation

The Correct Answer is D

A. The fetus is in distress: Fetal distress often presents as decelerations or an abnormal baseline heart rate, not accelerations.

B. The mother is in severe pain: Maternal pain does not cause fetal heart accelerations.

C. Uteroplacental insufficiency: This condition is associated with late decelerations, not accelerations.

D. A well-oxygenated fetus: FHR accelerations indicate adequate oxygenation and a reactive, healthy fetal status.

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Correct Answer is B

Explanation

A. Place a soft pillow under the client’s buttocks: Provides comfort but does not directly address pain or inflammation.

B. Apply an ice pack to the perineum: Reduces swelling and provides pain relief in the early postpartum period.

C. Prepare a warm sitz bath: Useful after the first 24 hours to promote healing and comfort, not immediately.

D. Position a heating lamp towards the episiotomy: Could increase discomfort and swelling in the acute phase.

A. Cover the cord with a sterile, moist saline dressing B. Explain to the client what is happening. C. Place the client in a knee-chest or Trendelenburg position. D. Prepare the client for an emergency cesarean birth.

Correct Answer is C

Explanation

A. Cover the cord with a sterile, moist saline dressing: While necessary to prevent cord drying, the first priority is to relieve pressure on the cord.

B. Explain to the client what is happening: Providing information is important but not the priority in an emergency.

C. Place the client in a knee-chest or Trendelenburg position: This action uses gravity to relieve pressure on the umbilical cord, promoting fetal oxygenation.

D. Prepare the client for an emergency cesarean birth: This is necessary but secondary to ensuring immediate cord decompression.

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The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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