A nurse is analyzing a fetal heart monitor strip and identifies a sinusoidal fetal heart rate pattern, which has been occurring for 30 min. Which of the following actions should the nurse take at this time?
Decrease the client's IV fluids
Prepare the client for an emergent birth.
Turn the client to a supine position
Document the findings.
The Correct Answer is B
A) Decrease the client's IV fluids:
Sinusoidal fetal heart rate patterns are concerning and typically indicate severe fetal distress, which is often associated with conditions such as fetal anemia, hypoxia, or central nervous system (CNS) damage. Decreasing IV fluids is not an appropriate response to a sinusoidal pattern. The primary focus should be on fetal well-being, not fluid management, in this situation.
B) Prepare the client for an emergent birth:
This pattern is typically associated with severe fetal compromise and is an ominous sign. Immediate intervention is required, and emergent delivery may be necessary to prevent further fetal distress and potential harm. The nurse should promptly notify the healthcare provider and prepare the client for an emergency cesarean delivery or other urgent interventions.
C) Turn the client to a supine position:
The supine position is not recommended for managing fetal distress, as it may decrease uterine blood flow and worsen the situation, especially if the fetus is experiencing hypoxia. The appropriate intervention for addressing a sinusoidal heart rate pattern is not repositioning the client in a supine position, but rather preparing for emergency delivery and providing immediate support to stabilize both mother and fetus.
D) Document the findings:
While it is important to document any fetal heart rate pattern, sinusoidal patterns require immediate action. Documentation alone is not sufficient in this case, as it does not address the potential life-threatening situation for the fetus. The nurse should not delay action, and the focus should be on preparing for emergency birth and notifying the healthcare provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
Naegele's Rule is a method used to estimate the due date of a pregnancy. It involves the following steps:
- Start with the first day of the client's last menstrual period (LMP).
- Add one year.
- Subtract three months.
- Add seven days.
Using the client's LMP of September 17:
- Start with September 17.
- Add one year: September 17, the following year.
- Subtract three months: June 17 of the following year.
- Add seven days: June 24.
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