When interpreting a fetal monitoring tracing, which of the following findings would require the nurse to intervene?
Presence of late decelerations.
Variability in fetal heart rate of 12 bpm.
Accelerations in fetal heart rate.
Baseline fetal heart rate of 140 bpm.
The Correct Answer is A
Choice A rationale
Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia. They occur after the peak of a contraction and indicate that the fetus is not receiving enough oxygen. This requires immediate intervention to improve fetal oxygenation and prevent fetal distress.
Choice B rationale
Variability in fetal heart rate of 12 bpm is considered moderate variability, which is a reassuring sign of fetal well-being. It indicates that the fetus has a healthy autonomic nervous system and is not in distress.
Choice C rationale
Accelerations in fetal heart rate are also a reassuring sign. They indicate that the fetus is well-oxygenated and responding appropriately to stimuli. No intervention is needed for accelerations.
Choice D rationale
A baseline fetal heart rate of 140 bpm is within the normal range (110-160 bpm) and does not indicate any immediate concern. It is a sign of a healthy, well-oxygenated fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This statement is incorrect. Vagus nerve stimulation actually decreases FHR variability. The vagus nerve, part of the parasympathetic nervous system, slows the heart rate and reduces variability.
Choice B rationale
This statement is correct. Baroreceptors are sensors located in blood vessels that help regulate blood pressure by detecting changes in the stretch of the vessel walls. They play a crucial role in maintaining stable blood pressure levels.
Choice C rationale
This statement is correct. The autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems, controls the fetal heart rate. It regulates the balance between heart rate acceleration and deceleration.
Choice D rationale
This statement is correct. Chemoreceptors respond to changes in blood gas levels, such as oxygen and carbon dioxide. They help regulate respiratory and cardiovascular responses to maintain homeostasis.
Correct Answer is D
Explanation
A. Chest physiotherapy can help mobilize secretions, but it primarily aids in clearing secretions rather than directly thinning them. While it may be beneficial as part of a comprehensive approach, it is not the most direct method for thinning secretions.
B. Prelubricating the suction catheter with saline does not effectively thin secretions. In fact, using saline in this way may introduce moisture that could inadvertently lead to complications, such as introducing infection or causing the client to cough.
C. While hyperventilation and providing oxygen are important for maintaining oxygen saturation during suctioning, this method does not help in thinning secretions. It may be used to ensure oxygenation during suctioning but is not effective for secretion management.
D. Providing humidified oxygen is an effective way to thin secretions. Humidity adds moisture to the airways, which can help to keep secretions less viscous and easier to clear. This is a standard practice in managing secretions in clients with tracheostomies.
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