A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?
Recurrent variable deceleration of the FHR
Uterine contractions every 6 min
Uterine contractions lasting 30 to 45 seconds
Moderate variability of the FHR
The Correct Answer is A
A. Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B. Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C. Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D. Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,A,B,C
Explanation
Correct Answer is D
Explanation
A. A bulging anterior fontanel suggests increased intracranial pressure, not dehydration.
B. Decreased urine specific gravity can occur with hydration or dilute urine, and it is not specific to dehydration.
C. Bounding pulses may be present in various conditions but are not a direct sign of dehydration.
D. Decreased skin turgor is a classic sign of dehydration in both infants and adults. It indicates a deficit of body fluids.
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