What is the most likely cause for variable fetal heart rate (FHR) decelerations?

Fetal hypoxemia.

Altered fetal cerebral blood flow.

Uteroplacental insufficiency.

Umbilical cord compression.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Fetal hypoxemia, a deficiency in oxygen reaching the fetal tissues, typically manifests as late decelerations in the fetal heart rate tracing, which reflect uteroplacental insufficiency. While severe hypoxemia can lead to various FHR patterns, variable decelerations are more directly associated with mechanical factors affecting the umbilical cord.

Choice B rationale

Altered fetal cerebral blood flow can be a consequence of various factors, including hypoxemia and cord compression, and can influence the fetal heart rate. However, variable decelerations are specifically caused by events that directly impede blood flow through the umbilical vessels rather than a generalized alteration in cerebral circulation.

Choice C rationale

Uteroplacental insufficiency, a condition where the placenta is unable to deliver an adequate supply of oxygen and nutrients to the fetus, typically results in late decelerations, indicating fetal distress due to chronic hypoxia. Variable decelerations, in contrast, have a more abrupt onset and recovery, reflecting acute changes in umbilical cord blood flow.

Choice D rationale

Umbilical cord compression occurs when the umbilical cord, which carries oxygen and nutrients to the fetus, is squeezed or constricted. This compression leads to a transient decrease in fetal blood flow and oxygenation, resulting in a rapid drop and subsequent return of the fetal heart rate, which is characteristic of variable decelerations. The shape, timing, and abrupt nature of variable decelerations directly correlate with the intermittent pressure on the umbilical cord.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Maintaining a patent airway is the immediate priority in the event of a seizure associated with eclampsia. During a seizure, the client's respiratory muscles may become compromised, leading to airway obstruction and hypoxemia, which can be detrimental to both the mother and the fetus. Ensuring a clear airway allows for adequate oxygenation.

Choice B rationale

While administering oxygen is important in managing eclampsia to address potential hypoxemia, establishing and maintaining a clear airway takes precedence. Without a patent airway, supplemental oxygen delivery will be ineffective. Oxygen administration typically follows ensuring airway patency.

Choice C rationale

Assessing blood pressure and fetal heart rate is crucial in monitoring the progression of preeclampsia and eclampsia, but it is not the immediate first action during an eclamptic seizure. The immediate concern is the client's airway and preventing injury during the seizure. Monitoring follows stabilization of the airway.

Choice D rationale

Magnesium sulfate is the medication of choice to prevent and treat eclamptic seizures. However, during an active seizure, the immediate priority is to ensure the client's safety and airway. Magnesium sulfate administration would follow the initial steps of airway management and seizure precautions.

A. Monitor deep tendon reflexes hourly. B. Notify the physician if urinary output is less than 30 ml per hour. C. Keep calcium gluconate on hand in case of a magnesium sulfate overdose. D. Monitor maternal vital signs every 6 hours. E. Monitor intake and output hourly. F. Monitor renal function and cardiac function closely.

Correct Answer is ["A","B","C","E","F"]

Explanation

Choice A rationale

Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.

Choice B rationale

A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.

Choice C rationale

Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.

Choice E rationale

Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.

Choice F rationale

Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

What is the most likely cause for variable fetal heart rate (FHR) decelerations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a pregnant client with preeclampsia.The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the nurse's first action is to:

Correct Answer is A

Explanation

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.Select all nursing interventions that apply in the care for the client.

Correct Answer is ["A","B","C","E","F"]

Explanation

To prevent heat loss from convection in a newborn, which action by the nurse is best?

The student nurse learns that the process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as:

A multiparous client, 28 hours after a cesarean birth, who is breastfeeding, has severe cramps or afterpains.The nurse explains that these are caused by:

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out.Which intervention would the nurse expect to include in the plan of care for this client?

A nurse is caring for a newborn immediately following birth who has a large abdominal wall defect that is protruding from the right of the umbilicus and is not covered by a membrane.Which of the following actions should the nurse take?

A patient with pregnancy-induced hypertension is admitted complaining of a pounding headache, visual changes, and epigastric pain.Nursing care is based on the knowledge that these signs indicate:

A nurse is caring for a 30-year-old female client who is at 20 weeks of gestation in the labor and delivery unit. Exhibits Upon reviewing the client’s medical record, the nurse determines that the client is at risk for developing dropdown and dropdown.