While caring for a client in labor, which assessment finding best indicates fetal well-being to the nurse?

Presence of late decelerations with each contraction during monitoring

Increased fetal movement between contractions

Fetal heart rate of 160 beats per minute with moderate variability

Fetal heart rate consistently below 120 beats per minute with no accelerations

Answer and Explanation

The Correct Answer is C

A. "Presence of late decelerations with each contraction during monitoring."
Late decelerations indicate uteroplacental insufficiency, which can lead to fetal hypoxia and distress. This is not a reassuring sign.

B. "Increased fetal movement between contractions."
While fetal movement is a positive sign, it is not the best indicator of fetal well-being in labor. Continuous FHR monitoring provides a better assessment.

C. "Fetal heart rate of 160 beats per minute with moderate variability."
A normal fetal heart rate (FHR) is 110–160 bpm, and moderate variability (6–25 bpm fluctuations) indicates a well-oxygenated fetus with an intact autonomic nervous system.

D. "Fetal heart rate consistently below 120 beats per minute with no accelerations."
A persistent FHR below 110 bpm (bradycardia) or minimal variability suggests possible fetal compromise.

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Correct Answer is B

Explanation

A. "The recommendation for you is about 15 to 25 pounds."
This recommendation is appropriate for clients who are overweight (BMI 25–29.9), not those with a normal BMI.

B. "A gain of about 25 to 35 pounds is recommended for you."
A BMI of 23.5 falls within the normal range (18.5–24.9). The recommended total weight gain for clients with a normal BMI is 25–35 lbs (11.3–15.9 kg) during pregnancy to support fetal growth and maternal health.

C. "A gain of about 1 pound per week is the best pattern for you."
While the recommended weight gain in the second and third trimesters is about 1 lb/week, total weight gain is individualized based on pre-pregnancy BMI.

D. "It would be best if you gained about 11 to 20 pounds."
This is the recommendation for obese clients (BMI ≥30), not those with a normal BMI.

A. Fetal heart rate (FHR) B. Bowel sounds C. Respiratory rate D. Temperature

Correct Answer is C

Explanation

A. Fetal heart rate (FHR): While FHR monitoring is important, the priority is assessing the mother's respiratory status due to the risk of magnesium toxicity, which can lead to respiratory depression.

B. Bowel sounds: Magnesium sulfate can cause decreased gastrointestinal motility, but bowel sounds are not the immediate priority. The nurse should monitor for paralytic ileus, but respiratory function takes precedence.

C. Respiratory rate: Magnesium sulfate is a central nervous system (CNS) depressant that can cause respiratory depression if levels become too high. A respiratory rate below 12 breaths per minute is a sign of magnesium toxicity, requiring immediate intervention (e.g., stopping the infusion and administering calcium gluconate).

D. Temperature: Temperature is not directly affected by magnesium sulfate administration, making it a lower-priority assessment compared to respiratory rate.

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While caring for a client in labor, which assessment finding best indicates fetal well-being to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at the first prenatal visit who has a BMI of 23.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is C

Explanation

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