Which of the following findings on fetal monitor tracing would be of most concern to the nurse?
Occasional accelerations.
Minimal or absent baseline variability.
Presence of early decelerations.
Fetal heart baseline of 160.
The Correct Answer is B
Choice A rationale
Occasional accelerations in fetal heart rate are generally reassuring, indicating fetal well-being and a positive response to movement or contractions.
Choice B rationale
Minimal or absent baseline variability is concerning because it can signal fetal hypoxia or central nervous system depression, indicating potential compromise in fetal oxygenation and well-being.
Choice C rationale
Early decelerations typically coincide with contractions and are often benign, resulting from fetal head compression that momentarily decreases heart rate but does not indicate distress.
Choice D rationale
A fetal heart baseline of 160 beats per minute is within the normal range (110-160 bpm), signifying an adequate fetal heart rate and not indicating immediate concern for the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Starting Pitocin at a low dose minimizes the risk of uterine hyperstimulation, which can cause fetal distress. Gradually increasing the dose allows careful monitoring of the mother’s and fetus’s responses for optimal contraction rate.
Choice B rationale
Administering Pitocin without starting at a low dose increases the risk of uterine tachysystole, leading to potential complications like uterine rupture or placental abruption. A gradual increase ensures safer labor progression.
Correct Answer is B
Explanation
Choice A rationale
Contractions spaced 5 to 20 minutes apart can indicate early labor, but regular and intense contractions closer together suggest active labor. This does not indicate imminent hospital visit.
Choice B rationale
Regular contractions lasting about a minute and causing inability to talk through them are strong indicators of active labor, suggesting the need for hospital evaluation.
Choice C rationale
Seeing a pink discharge (bloody show) indicates the cervix is starting to dilate but does not necessarily mean active labor is present. It's not the most immediate sign to proceed to hospital.
Choice D rationale
Cramping for 4 hours can be a sign of early labor, but it lacks the regularity and intensity of active labor contractions. This does not suggest an immediate need for hospital visit.
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