A nurse caring for a client who is in labor identifies a baseline fetal heart rate of 150/min with moderate variability and accelerations present. Occasional variable decelerations uterine contractions occur every 4 min, lasting 90 to 100 seconds. Which of the following documentation should the nurse use to represent this fetal heart rate pattern?
Category I
Category Il
Uncategorized
Category III
The Correct Answer is B
A) Category I:
Category I fetal heart rate patterns are considered normal and are characterized by a baseline fetal heart rate of 110–160 beats per minute, moderate variability, and the presence of accelerations. The pattern also lacks concerning decelerations. While this client’s fetal heart rate is within the normal baseline range (150 bpm), the presence of occasional variable decelerations indicates that the fetal heart rate pattern does not meet the criteria for Category I.
B) Category II:
Category II includes all fetal heart rate patterns that are not classified as Category I or III. This category represents indeterminate or concerning patterns, which require ongoing assessment and interventions. In this case, the fetal heart rate pattern includes a baseline within the normal range, moderate variability, accelerations, but also occasional variable decelerations. Variable decelerations, particularly when they occur intermittently, are often considered non-reassuring but not immediately concerning if they resolve quickly, placing the pattern in Category II.
C) Uncategorized:
"Uncategorized" refers to situations where the fetal heart rate pattern cannot be classified due to insufficient information or an unclear pattern. This is not applicable here because the nurse has identified sufficient data to classify the pattern.
D) Category III:
Category III patterns are considered abnormal and require prompt intervention. These patterns are characterized by persistent decelerations, such as late decelerations, bradycardia, or variable decelerations that do not resolve with interventions. Since the variable decelerations in this case are occasional and not persistent or severe, this pattern does not meet the criteria for Category III.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.6"]
Explanation
Given:
Desired dose: Ceftazidime 1 g IM every 6 hours
Available concentration: Ceftazidime 280 mg/mL
To find:
Volume to administer (in mL)
Step 1: Convert desired dose to milligrams
1 gram (g) is equal to 1000 milligrams (mg).
Multiply by 1000:
Desired dose (mg) = Desired dose (g) x 1000
Desired dose (mg) = 1 g x 1000 = 1000 mg
Step 2: Set up the proportion
We can use the following proportion to solve the problem:
(Desired dose) / (Available concentration) = Volume to administer
Step 3: Substitute the values
Plugging in the given values, we get:
(1000 mg) / (280 mg/mL) = Volume to administer
Step 4: Simplify
To simplify, we can invert the denominator and multiply:
(1000 mg) x (1 mL / 280 mg) = Volume to administer
The "mg" units cancel out, leaving us with:
(1000 x 1 mL) / 280 = Volume to administer
Step 5: Calculate
Performing the multiplication and division, we get:
1000 mL / 280 = Volume to administer
3.57 mL ≈ Volume to administer
Step 6: Round to the nearest tenth
3.6mL
Correct Answer is B
Explanation
A) Right upper quadrant:
The right upper quadrant would not be the most appropriate place to auscultate the fetal heart rate in this scenario. In a vertex presentation with the fetal back on the left side, the best location for auscultation is typically along the fetal back, which is on the left side of the mother. The right upper quadrant would place you over the small parts of the fetus (limbs, hands, etc.), which generally would not be where the fetal heart rate is best heard.
B) Left upper quadrant:
The left upper quadrant is the most appropriate area to begin auscultation for this fetal heart rate (FHR) pattern. In this position, the fetal back is positioned towards the left side of the mother's abdomen, and the heart rate is typically heard most clearly over the back. The left upper quadrant would be over the fetal back, making it the best location to auscultate the FHR accurately.
C) Right lower quadrant:
The right lower quadrant would not be ideal for auscultating the fetal heart rate in this scenario. Since the fetal back is on the left side, the right lower quadrant would likely be over the fetal small parts (arms and legs), where the FHR would be harder to distinguish.
D) Left lower quadrant:
Although the left lower quadrant is on the left side of the mother, it's closer to the pelvic area and may be less effective for auscultating the fetal heart rate in this vertex presentation. It's more likely to be over the lower parts of the fetus, potentially interfering with accurate heart rate auscultation.
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