The RN interprets the following external fetal monitoring strip as:
Urgent: Maternal fever due to chorioamnionitis.
Non-urgent: Compression due to lack of amniotic fluid.
Urgent: Umbilical cord prolapse due to head not being engaged in the pelvic cavity.
Non-urgent: Progression of the fetal head through the vaginal canal.
The Correct Answer is C
Choice A rationale
Maternal fever due to chorioamnionitis would show maternal signs of infection and not directly indicate fetal heart rate changes typical of umbilical cord prolapse.
Choice B rationale
Compression due to lack of amniotic fluid (oligohydramnios) typically shows variable decelerations on the fetal monitoring strip but is not urgent without other symptoms.
Choice C rationale
Umbilical cord prolapse is an urgent condition where the umbilical cord slips ahead of the fetus and can be indicated by sudden severe variable decelerations on the fetal monitor strip, requiring immediate intervention.
Choice D rationale
Progression of the fetal head through the vaginal canal shows a gradual change in the fetal heart rate and not the sudden pattern seen with cord prolapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
- Blood pressure 160/105 mm Hg: This is abnormal as it is significantly elevated, which is a key indicator of preeclampsia.
- Reflexes 3+: This is abnormal and indicates hyperreflexia, often seen in preeclampsia.
- Platelet count 140,000/mm³: This is abnormal since it is on the lower end, suggesting mild thrombocytopenia, common in preeclampsia.
- Temperature 37.2°C: This is normal for a pregnant individual.
- Oxygen saturation 97%: This is normal, indicating adequate oxygenation.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Gestational age helps assess fetal development and potential complications. It is essential information for the provider to determine appropriate care and interventions.
Choice B rationale
Vaginal examination findings provide insight into cervical dilation, effacement, and station, which are critical for monitoring labor progress and making informed decisions about labor management.
Choice C rationale
Uterine contractions are a key indicator of labor progress. The frequency, duration, and intensity of contractions help the provider assess labor progression and plan necessary interventions.
Choice D rationale
Birthing parent's blood pressure is crucial for monitoring maternal well-being, especially in cases of pre-eclampsia or other hypertensive disorders. Elevated blood pressure can indicate complications that require immediate attention.
Choice E rationale
Birthing parent's report of pain, while important for comfort measures, is subjective and less critical for immediate clinical decision-making compared to the other findings.
Choice F rationale
Fetal heart rate monitoring provides essential information about the baby's well-being during labor. Abnormal heart rate patterns can indicate fetal distress and necessitate prompt intervention.
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