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) Milia:
Milia are tiny white or yellowish cysts that appear on a newborn's face, particularly on the nose, chin, or forehead. They are caused by the accumulation of keratin under the skin. Milia usually disappear within a few weeks of life and are not related to the pinkish marks described in the question.
B) Telangiectatic nevi (stork bites):
This finding is consistent with telangiectatic nevi, also known as stork bites. These are flat, irregular, pinkish-red marks often found on the forehead, eyelids, and nape of the neck. They are caused by dilated capillaries in the skin and are common in newborns. The marks blanch when pressed and are usually harmless, disappearing within the first 1-2 years of life. This is the correct answer based on the description provided in the question.
C) Nevus flammeus (port wine stain):
A port wine stain is a dark red to purple, flat birthmark caused by capillary malformations. Unlike stork bites, a port wine stain does not blanch when pressed and is typically present for life. It usually appears on the face, neck, or arms, and the coloration remains the same over time.
D) Nevus vasculosus (strawberry mark):
A strawberry mark is a raised, red, and bumpy birthmark that results from proliferation of capillaries. These marks typically appear in the first few weeks of life and grow in size before eventually shrinking and disappearing by the age of 5-10 years. Strawberry marks are not flat, pinkish, or blanchable, making this option unlikely in the scenario described.
Correct Answer is ["C","E","H","I"]
Explanation
Findings that require follow-up:
Uterus boggy at 24 hr postpartum:
A boggy uterus indicates poor uterine contraction, which can lead to postpartum hemorrhage. Effective uterine contraction is crucial to prevent excessive bleeding after delivery, and this finding warrants immediate intervention, such as fundal massage or administering uterotonic medications.
Lochia rubra with foul odor:
Foul-smelling lochia is a sign of potential infection, often indicative of endometritis, which is an infection of the uterine lining. The presence of this odor requires prompt follow-up and possibly antibiotic treatment to prevent further complications.
Elevated temperature (38.3°C/100.9°F) at 24 hr postpartum:
A postpartum fever may indicate infection, such as endometritis or a urinary tract infection (UTI). This fever should be investigated further to determine the cause and appropriate treatment, as untreated infections can lead to serious complications.
Increased heart rate (105/min) at 24 hr postpartum:
Tachycardia in the postpartum period can be a sign of infection or early signs of hemodynamic instability, possibly due to blood loss or infection. Close monitoring is necessary, and the healthcare provider should be notified to evaluate the cause and initiate treatment if necessary.
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