While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
Maternal pulse rate of 100 bpm.
Maternal blood pressure of 120/70 mm Hg.
Decrease in intensity of uterine contractions.
Persistent fetal bradycardia below 100 bpm.
The Correct Answer is D
The correct answer is: d. Persistent fetal bradycardia below 100 bpm.
Choice A: Maternal pulse rate of 100 bpm
A maternal pulse rate of 100 beats per minute (bpm) is slightly elevated but not uncommon during labor due to the physical exertion and stress involved. The normal range for an adult’s resting heart rate is typically between 60 and 100 bpm. While it is important to monitor the maternal pulse, it is not an immediate cause for concern unless accompanied by other symptoms such as hypotension, chest pain, or signs of distress.
Choice B: Maternal blood pressure of 120/70 mm Hg
A maternal blood pressure of 120/70 mm Hg is within the normal range. Normal blood pressure for adults is generally considered to be around 120/80 mm Hg. This reading indicates that the mother is maintaining stable blood pressure during labor, which is a positive sign. Therefore, this does not require immediate reporting to the physician.
Choice C: Decrease in intensity of uterine contractions
A decrease in the intensity of uterine contractions can be concerning as it may indicate ineffective labor, which could prolong the delivery process. However, this is typically managed by adjusting oxytocin levels or other interventions and does not require immediate reporting unless it leads to other complications such as fetal distress.
Choice D: Persistent fetal bradycardia below 100 bpm
Persistent fetal bradycardia below 100 bpm is a significant concern and should be immediately reported to the physician. Normal fetal heart rate ranges from 110 to 160 bpm. Bradycardia, defined as a heart rate below 110 bpm, can indicate fetal distress, hypoxia, or other complications that may require urgent intervention to ensure the safety of the fetus. Persistent bradycardia, especially below 100 bpm, necessitates immediate medical attention to assess and address the underlying cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Dehydration. A significantly indented anterior fontanelle in a newborn is most commonly a sign of dehydration.
Choice A reason:
Increased intracranial pressure: This statement is incorrect because increased intracranial pressure typically causes a bulging, not indented, fontanelle. Symptoms include irritability, vomiting, and a high-pitched cry.
Choice B reason:
Vernix caseosa: This statement is incorrect because vernix caseosa is a white, cheesy substance covering the skin of newborns, unrelated to fontanelle indentation. It serves as a protective layer for the baby’s skin.
Choice C reason:
Dehydration: This statement is correct. Dehydration in newborns can cause a sunken fontanelle due to the loss of fluid. Other signs include dry mouth, sunken eyes, and fewer wet diapers.
Choice D reason:
Cyanosis: This statement is incorrect because cyanosis refers to a bluish discoloration of the skin due to lack of oxygen, not related to fontanelle shape. It indicates issues with oxygenation or circulation.
Correct Answer is A
Explanation
Choice A reason:
The tonic neck reflex, also called the fencing posture, occurs when a baby's head is turned to one side. The arm and leg on that side stretch out, while the opposite arm and leg bend up at the elbow. This reflex lasts until the baby is about 5 to 7 months old. This reflex matches the description of the question.
Choice B reason:
The Moro reflex, also called the startle reflex, is the baby's reaction to being startled. The cause is often a loud sound, a sudden movement, or even their own cry. As an adult, you may jump or gasp when you are startled. A baby will throw back their head, extend their arms and legs, cry, then pull their arms and legs back in. This reflex does not match the description of the question.
Choice C reason:
The startled reflex is not a distinct reflex in newborns. It is another name for the Moro reflex, which is explained.
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