A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

Fetal head compression

Polyhydramnios

Maternal fever

Umbilical cord compression

Answer and Explanation

The Correct Answer is D

Choice A reason:
Fetal head compression is incorrect, as this factor can cause early decelerations in the fetal heart rate. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. Fetal head compression occurs as the fetus descends into the birth canal and does not pose a threat to the fetal well-being.

Choice B reason:
Polyhydramnios is incorrect, as this factor can cause variable or late decelerations in the fetal heart rate, depending on the underlying cause. Polyhydramnios refers to an excessive amount of amniotic ﬂuid, which can result from fetal anomalies, maternal diabetes, multiple gestation, or other conditions. Polyhydramnios can cause umbilical cord prolapse, uterine overdistension, or placental abruption, leading to reduced blood ﬂow and oxygen delivery to the fetus.

Choice C reason:
Maternal fever is incorrect, as this factor can cause late decelerations in the fetal heart rate. Late decelerations are symmetrical decreases in the FHR that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency. Maternal fever can increase maternal and fetal metabolism and oxygen demand, leading to fetal hypoxia and acidosis.

Choice D reason:
Umbilical cord compression is correct, as this factor can cause variable decelerations in the fetal heart rate. Variable decelerations are abrupt decreases in the FHR that vary in onset, duration, and depth, which indicate umbilical cord compression and reduced blood ﬂow to the fetus. Umbilical cord compression can occur due to cord prolapse, nuchal cord, short cord, or other causes. The nurse should reposition the client, administer oxygen, and prepare for delivery if indicated.

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Correct Answer is A

Explanation

Choice A reason:

Panting can help prevent premature pushing and reduce the risk of cervical edema or laceration. The client should be instructed to take short, shallow breaths through her mouth during contractions until she reaches 10 cm of dilation.

Choice B reason:

Assessing the perineum for signs of crowning is not a priority at this stage, as the fetus is not yet at a low enough station to be visible. Crowning usually occurs when the fetus is at +4 or +5 station.

Choice C reason:

Assisting the client into a comfortable position is important, but it does not address the urge to push. The client should be encouraged to change positions frequently to promote fetal descent and comfort.

Choice D reason:

Helping the client to the bathroom to empty her bladder is not advisable, as it can increase the risk of cord prolapse or rupture of membranes. The client should have an indwelling catheter inserted if she is unable to void spontaneously.

A. Precipitous birth B. Small for gestational age newborn C. Two-vessel umbilical cord D. Gestational hypertension

Correct Answer is A

Explanation

Choice A reason: A precipitous birth is a delivery that occurs in less than 3 hours from the onset of labor. This can cause uterine atony, which is the failure of the uterus to contract and compress the blood vessels after the placenta is delivered. Uterine atony is the most common cause of postpartum hemorrhage²³.

Choice B reason: A small for gestational age newborn is not a risk factor for postpartum hemorrhage. It may be associated with other conditions, such as placental insufficiency or intrauterine growth restriction, but these do not directly increase the risk of bleeding after delivery.

Choice C reason: A two-vessel umbilical cord is a cord that has one artery and one vein instead of the normal two arteries and one vein. This can be a marker for congenital anomalies or placental abnormalities, but it does not increase the risk of postpartum hemorrhage by itself.

Choice D reason: Gestational hypertension is a condition where the blood pressure rises above 140/90 mm Hg after 20 weeks of pregnancy. It can lead to complications such as preeclampsia, eclampsia, or HELLP syndrome, which can aﬀect the clotting system and cause bleeding disorders. However, gestational hypertension alone does not increase the risk of postpartum hemorrhage unless it is associated with these severe conditions¹⁴.

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A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Correct Answer is A

Explanation

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