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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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Correct Answer is C

Explanation

This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.

Choice A: Obtain a full history is wrong because it is not the most urgent action.

A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.

Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.

Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.

Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.

Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.

A. The increase in the level of placental hormones tends to result in chelation of maternal iron. B. Fetal demand for iron is greater than the maternal intake. C. During the latter half of pregnancy, the maternal intestinal absorption of iron is decreased. D. The increase in maternal blood volume is greater than the increase in maternal red blood cells.

Correct Answer is D

Explanation

The correct answer is choice D. The increase in maternal blood volume is greater than the increase in maternal red blood cells.

This means that the concentration of hemoglobin and hematocrit in the blood is diluted by the extra fluid.

This is a normal physiological adaptation to pregnancy and does not indicate iron deficiency anemia.

Choice A is wrong because placental hormones do not chelate maternal iron.

Chelation is a process of binding metal ions to organic molecules, which is not relevant to this question.

Choice B is wrong because fetal demand for iron is not greater than maternal intake.

The mother can meet the iron needs of the fetus by increasing her dietary intake and taking iron supplements.

Choice C is wrong because maternal intestinal absorption of iron is not decreased during pregnancy.

In fact, it may be increased due to higher levels of estrogen and progesterone.

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

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Naxlex Comprehensive Predictor Exams

A 23-year-old primigravida who appears to be in her third trimester of pregnancy comes to the labor and delivery unit reporting acute abdominal pain. She has had no prenatal care. Which assessment should the nurse do first?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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