Which of the following changes in the fetal heart rate (FHR) should a nurse report to the provider for a client who is in labor and receiving epidural analgesia?
Early decelerations of the FHR
FHR accelerations of 15/min for 15 seconds
FHR increase to 150/min
Prolonged period of absent FHR variability
The Correct Answer is D
Choice A reason: Early decelerations of the FHR result from head compression during contractions, a benign response reflecting vagal stimulation. They mirror contraction patterns and do not indicate fetal distress. Epidural analgesia may reduce maternal blood pressure, but early decelerations are unrelated to hypoxia, requiring no immediate reporting in this context.
Choice B reason: FHR accelerations of 15 beats/min for 15 seconds indicate fetal well-being, reflecting a responsive autonomic nervous system. They occur with fetal movement or stimulation and are not concerning. Epidural analgesia does not typically cause accelerations, and these findings do not warrant reporting, as they signify normal fetal oxygenation and neurological function.
Choice C reason: An FHR of 150/min is within the normal range (110-160/min) and does not indicate distress. Epidural analgesia may cause maternal hypotension, affecting placental perfusion, but a stable FHR within normal limits reflects adequate fetal oxygenation. This finding does not require immediate reporting, as it aligns with normal fetal physiology.
Choice D reason: Prolonged absent FHR variability suggests fetal compromise, as variability reflects autonomic nervous system function and oxygenation. Epidural analgesia can cause maternal hypotension, reducing placental perfusion and leading to hypoxia, which diminishes variability. This critical finding requires immediate reporting to address potential fetal distress and prevent adverse outcomes like acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assisting with showering twice daily does not support traditional yin-yang postpartum practices, which prioritize warmth to restore energy balance and promote healing. Frequent exposure to water, especially if cool, may introduce cold or dampness, disrupting the body’s qi and hindering recovery. This practice is not scientifically aligned with the warming principles of yin-yang balance, which are critical for postpartum recuperation in traditional Chinese medicine.
Choice B reason: Providing a warm beverage aligns with yin-yang principles, as warmth supports the body’s yang energy, aiding recovery by promoting blood flow and energy restoration. In traditional Chinese medicine, warm fluids help balance the body’s qi, counteracting the cold yin state of postpartum. This practice supports physiological healing by maintaining hydration and warmth, essential for tissue repair and energy balance.
Choice C reason: Maintaining a cool environment contradicts yin-yang postpartum care, which emphasizes warmth to restore energy balance. A cool environment may exacerbate the cold yin state, potentially slowing recovery by reducing blood flow and energy circulation. Scientifically, a cooler environment does not support the thermoregulatory needs of a postpartum body, which requires warmth to promote healing and comfort.
Choice D reason: Applying ice packs to the perineal area introduces cold, which opposes yin-yang principles that favor warmth to restore balance and promote healing. Cold can constrict blood vessels, potentially slowing tissue repair. While ice may reduce swelling, it conflicts with traditional practices that prioritize warming therapies to support postpartum recovery and energy flow in the body.
Correct Answer is C
Explanation
Choice A reason: Not feeling fetal movement at 12 weeks is normal, as quickening typically begins at 16-20 weeks. Fetal movement is not expected this early due to small fetal size and limited neuromuscular development. This finding does not indicate an emergency, as it aligns with normal gestational physiology.
Choice B reason: 2+ deep tendon reflexes at 38 weeks are normal, reflecting intact neurological function. Hyperreflexia (3+ or 4+) may suggest preeclampsia, but 2+ is not concerning. Reflexes are influenced by magnesium levels and neurological status, but this finding does not prioritize immediate provider attention compared to urgent symptoms like blurred vision.
Choice C reason: Blurred vision at 36 weeks suggests preeclampsia, as cerebral edema or vasoconstriction affects visual pathways. This symptom indicates severe features, risking seizures or stroke. Preeclampsia’s endothelial dysfunction elevates blood pressure, impairing cerebral perfusion, making this a medical emergency requiring immediate provider evaluation to prevent maternal and fetal complications.
Choice D reason: A fetal heart rate of 160/min at 28 weeks is within the normal range (110-160/min), indicating fetal well-being. Doppler assessment reflects autonomic function and oxygenation, and this rate does not suggest distress. Unlike blurred vision, which signals maternal complications, this finding does not require urgent provider attention.
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