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

Fetal head compression.

Umbilical cord compression.

Maternal fever.

Polyhydramnios.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Choice A, fetal head compression, is not the correct answer in this case. Fetal head compression can cause early decelerations in the FHR, not variable decelerations. Early decelerations are often a result of the fetal head being compressed during contractions and are considered benign and expected during labor.

Choice B rationale:

The correct answer is choice B, which is umbilical cord compression. Variable decelerations of the fetal heart rate (FHR) can occur during labor due to various rationales, and umbilical cord compression is one of the common causes. When the umbilical cord gets compressed, it can briefly reduce or restrict the blood flow and oxygen supply to the fetus, leading to temporary decelerations in the FHR.

Choice C rationale:

Choice C, maternal fever, is also not the correct answer for variable decelerations in FHR. Maternal fever can be a sign of infection, and it may lead to other fetal heart rate abnormalities, such as tachycardia (an increased heart rate), but it is not specifically associated with variable decelerations.

Choice D rationale:

Choice D, polyhydramnios, is not the cause of variable decelerations in this scenario. Polyhydramnios refers to an excessive accumulation of amniotic fluid around the fetus. While it can have implications for pregnancy, it is not directly linked to variable decelerations of the FHR.

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Correct Answer is D

Explanation

The correct answer is choice d. Vastus lateralis.

Choice A rationale:

The deltoid muscle is not typically used for newborn injections because it is too small and underdeveloped, making it an inappropriate site for intramuscular injections in this age group.

Choice B rationale:

The dorsogluteal muscle is also not recommended for newborns due to the risk of injury to the sciatic nerve and the muscle’s underdevelopment.

Choice C rationale:

The ventrogluteal muscle, while a good site for older children and adults, is not commonly used for newborns because it is not as easily accessible and developed as the vastus lateralis.

Choice D rationale:

The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the preferred site for intramuscular injections in newborns. It is well-developed and provides a large muscle mass, making it the safest and most effective site for administering vitamin K.

A. Placenta previa. B. Preterm labor. C. Threatened abortion. D. Abruptio placentae.

Correct Answer is A

Explanation

Choice A rationale:

Painless, bright red vaginal bleeding at 36 weeks gestation is indicative of placenta previa. Placenta previa is a condition in which the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to efface and dilate. The bright red color of the blood is due to its fresh origin from the exposed placental vessels. This condition is painless because the bleeding occurs without uterine contractions.

Choice B rationale:

Preterm labor is not the correct answer in this scenario. Preterm labor refers to the onset of regular uterine contractions leading to cervical changes before 37 weeks of gestation. In this case, the key indicator is painless bleeding, which is not associated with uterine contractions.

Choice C rationale:

Threatened abortion is also not the correct answer. Threatened abortion is the term used when a pregnant woman experiences vaginal bleeding, but the cervix is closed, indicating that there is still a chance for the pregnancy to continue. However, the bleeding in placenta previa is unrelated to fetal viability and is specifically caused by the placental position.

Choice D rationale:

Abruptio placentae is not the correct answer either. Abruptio placentae, also known as placental abruption, is a condition where the placenta prematurely separates from the uterine wall before delivery. This can cause painful bleeding due to the blood being trapped between the placenta and uterine wall. In the given scenario, the bleeding is described as painless, which does not align with the characteristics of abruptio placentae.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?

Correct Answer is D

Explanation

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

Correct Answer is A

Explanation

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