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. Orange juice.This is because orange juice is rich in vitamin C, which enhances the absorption of iron from ferrous sulfate tablets.Vitamin C helps reduce iron to its ferrous form, which is more readily absorbed by the intestinal cells.
Choice A is wrong because milk contains calcium, which inhibits iron absorption by forming insoluble complexes with iron.Choice
B is wrong because tea contains tannins, which are polyphenols that bind to iron and decrease its bioavailability.Choice C is wrong because water does not have any effect on iron absorption, neither enhancing nor inhibiting it.
Normal ranges for serum iron are 50-170 mcg/dL for men and 40-150 mcg/dL for women.Normal ranges for hemoglobin are 13.5-17.5 g/dL for men and 12-15.5 g/dL for women.
Correct Answer is B
Explanation
This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus.Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.
Choice A is wrong because documenting the findings is not a priority action in this situation.
The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.
Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.
It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.
Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.
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