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A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

The fetal heart rate decreases after the start of a contraction and returns to the baseline 60 seconds after the end of the contraction.

There is a six to ten beat-to-beat variability in the fetal heart rate.

The fetal heart rate accelerates five to seven beats just prior to the beginning of a contraction.

The fetal heart rate decreases at the start of the contraction and returns to baseline by the end of the contraction.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A and it indicates fetal distress because it is a sign of late deceleration. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia and can lead to fetal acidosis and neurological damage.

Choice B is wrong because it indicates a normal variability in the fetal heart rate, which reflects a healthy autonomic nervous system. A normal fetal heart rate is 120-160 beats per minute.

Choice C is wrong because it indicates an early acceleration in the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.

Choice D is wrong because it indicates an early deceleration in the fetal heart rate, which is a normal response to fetal head compression during contractions.

It does not indicate fetal distress.

Normal ranges for fetal heart rate patterns are:

• Baseline: 120-160 beats per minute

• Variability: 6-25 beats per minute

• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds

• Decelerations: none or early (mirror contractions)

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Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D. Placing warmed tea bags on the nipples is not a recommended method to avoid nipple soreness while breastfeeding.Tea bags can cause dryness and cracking of the nipples, which can increase the risk of infection and pain.

Choice A is wrong because it is better to use both breasts at each feeding and switch the starting breast at each feeding.This helps to ensure adequate milk production and drainage.

Choice B is correct because rubbing breast milk into the nipple can help to moisturize and protect the nipple from infection.Breast milk has antibacterial and healing properties.

Choice C is correct because washing the nipples with water but no soap can help to prevent irritation and dryness of the nipples.

Soap can remove the natural oils that protect the skin.Letting the nipples air dry can also help to prevent fungal growth.

A. Offer her the opportunity for counseling to help her grieve. B. Encourage the woman to hold the deceased twin as well as the living twin. C. Remind her that she should be happy that one child survived and is healthy. D. Assist the woman to take pictures of both babies.

Correct Answer is C

Explanation

The correct answer is choice C. Reminding her that she should be happy that one child survived and is healthy is the least helpful nursing action in supporting the woman as she copes with her loss.

This statement minimizes her grief and implies that she should not feel sad about the deceased twin.

It also disregards her attachment to both babies and her need to mourn the loss of one of them.

Choice A is wrong because offering her the opportunity for counseling to help her grieve is a helpful nursing action that recognizes her emotional distress and provides her with professional support.

Choice B is wrong because encouraging the woman to hold the deceased twin as well as the living twin is a helpful nursing action that allows her to acknowledge and bond with both babies and to create memories that may facilitate healing.

Choice D is wrong because assisting the woman to take pictures of both babies is a helpful nursing action that provides her with tangible mementos of her twins and honors their

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A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse instructs a class of postpartum women on methods to avoid nipple soreness while breastfeeding. Which comment by a class participant indicates the need for further instruction?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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