When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?
Increase in baseline variability.
Non-periodic accelerations.
Early decelerations.
Variable decelerations.
The Correct Answer is D
Choice A rationale
An increase in baseline variability is generally considered a reassuring sign of fetal well-being, indicating a responsive central nervous system and adequate oxygenation. While important to monitor, it is not a specific periodic pattern to observe immediately following membrane rupture due to potential cord compression. Normal baseline variability ranges from 6 to 25 beats per minute.
Choice B rationale
Non-periodic accelerations are abrupt increases in fetal heart rate above the baseline, typically lasting less than 30 seconds. They are usually a reassuring sign, often occurring with fetal movement or stimulation. While their presence is noted, they are not the primary periodic pattern to observe immediately after membrane rupture for potential complications.
Choice C rationale
Early decelerations are gradual decreases in fetal heart rate that mirror the uterine contractions. They are thought to be caused by fetal head compression and are generally considered benign. While their presence is documented, they are not the most concerning pattern immediately after membrane rupture, which raises the risk of cord issues.
Choice D rationale
Variable decelerations are abrupt decreases in fetal heart rate that are variable in timing and shape in relation to uterine contractions. They are often caused by umbilical cord compression, which is a significant risk factor immediately following the rupture of membranes, as the fluid cushion around the cord is reduced. Prompt identification is crucial for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While addressing the client's feelings is important, dismissing the need for blood pressure monitoring is not appropriate nursing practice during pregnancy. Routine blood pressure checks are essential for detecting potential complications.
Choice B rationale
While blood pressure can increase in the second trimester due to physiological changes like increased blood volume, it doesn't invariably increase early in the second trimester, and this statement might cause unnecessary alarm if the client's blood pressure is currently normal.
Choice C rationale
Advanced maternal age (typically over 35) is a risk factor for gestational hypertension, but stating this directly without knowing the client's baseline blood pressure or other risk factors might be alarming and isn't the primary reason for routine monitoring at every prenatal visit.
Choice D rationale
Routine blood pressure monitoring is a standard component of prenatal care for all pregnant clients, regardless of their past medical history or perceived risk. This allows for the early detection of gestational hypertension or preeclampsia, which can develop even in women with previously normal blood pressure. Early detection and management are crucial for maternal and fetal well-being.
Correct Answer is C
Explanation
Choice A rationale
Immediately postpartum, the fundus is typically palpable. It gradually descends into the pelvic cavity over the following days.
Choice B rationale
By 6 to 12 hours postpartum, the fundus is usually located at the level of the umbilicus or slightly below it. It descends approximately one fingerbreadth (1 cm) per day.
Choice C rationale
In the immediate postpartum period, within the first few hours after delivery, the nurse should expect to find the fundus at the level of the umbilicus. This indicates that the uterus is contracting to control bleeding at the placental site.
Choice D rationale
Immediately after delivery, the fundus is typically higher than the symphysis pubis. It descends into the abdomen as the uterus contracts and the placental site begins to heal. .
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