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.
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)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
The correct answer is choice D. Presence of human chorionic gonadotropin (hCG) in blood.This is apositive sign of pregnancythat can only be attributed to a fetus.hCG is a hormone produced by the placenta that can be detected in blood or urine tests.
Choice A. Quickening.This is apresumptive sign of pregnancythat is based on the woman’s report of feeling fetal movements in her lower abdomen.This can occur at 16 weeks for second time moms and around 20 weeks for first time moms.However, this sign is not conclusive as other conditions can cause similar sensations.
Choice B. Uterine enlargement.This is aprobable sign of pregnancythat can be observed by the nurse or doctor through palpation.However, this sign does not mean 100% that a baby is growing in the uterus as it can be due to other causes such as fibroids or tumors.
Choice C. Urinary frequency.This is apresumptive sign of pregnancythat is based on the woman’s report of needing to urinate more often than usual.This can be caused by hormonal changes and increased blood volume during pregnancy.However, this sign is not definitive as other conditions such as urinary tract infections or diabetes can also cause frequent urination.
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