Which action should the nurse take?
Document the normal finding.
Notify the healthcare provider.
Schedule an ultrasound.
Obtain hematocrit level.
The Correct Answer is B
Choice A rationale
Documenting the finding without further action is inappropriate when faced with an abnormal FHR pattern. Immediate intervention is crucial to prevent potential fetal hypoxia or distress, necessitating a prompt response.
Choice B rationale
Notifying the healthcare provider is essential when encountering abnormal FHR patterns. Timely communication allows for appropriate interventions to be implemented, reducing the risk of adverse fetal outcomes and ensuring patient safety.
Choice C rationale
Scheduling an ultrasound is not the immediate priority when an abnormal FHR pattern is detected. Immediate clinical evaluation and interventions are necessary to address potential fetal distress or hypoxia.
Choice D rationale
Obtaining a hematocrit level is unrelated to the immediate management of abnormal FHR patterns. The priority is to address the fetal well-being and ensure adequate oxygenation through timely clinical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are abrupt decreases in fetal heart rate, unrelated to contractions and typically caused by umbilical cord compression. The described pattern does not match these characteristics.
Choice B rationale
Late decelerations occur when there is a gradual decrease in fetal heart rate starting after the contraction begins and returning to baseline after the contraction ends, often indicating utero-placental insufficiency.
Choice C rationale
No decelerations are present when there are no decreases in fetal heart rate. The scenario described includes a specific pattern of decelerations, making this choice incorrect.
Choice D rationale
Early decelerations are a gradual decrease in fetal heart rate that mirrors the contraction pattern, often caused by head compression during contractions. The pattern described does not fit early decelerations.
Correct Answer is C
Explanation
Choice A rationale
Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.
Choice B rationale
A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.
Choice C rationale
A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.
Choice D rationale
While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.
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