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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A: This infection does not directly cause hearing loss at birth. Hearing loss in newborns can be associated with genetic factors, birth complications, and certain infections, but GBS is not known to be a direct cause of hearing impairment.

B: A positive GBS test result does not necessitate a cesarean birth. The standard management for GBS-positive mothers is the administration of intrapartum antibiotic prophylaxis, not cesarean delivery, unless there are other obstetric indications.

C: Testing for GBS is typically done between 36 and 37 weeks of gestation because this timing is close to delivery, when the test results are most predictive of the baby's risk of exposure during birth.

D: Antibiotics are not given during the last 2 weeks of pregnancy to prevent GBS transmission. Instead, they are administered during labor to ensure effective levels of the drug during delivery, which is the critical period for preventing transmission to the baby.

A. Apply a warm pack to the puncture site prior to the procedure. B. Apply a mummy restraint to the newborn for the procedure. C. Apply antiseptic solution to the puncture site after the procedure. D. Elevate the extremity prior to the procedure.

Correct Answer is A

Explanation

A. Applying a warm pack to the puncture site before the procedure increases blood flow to the area, which makes the blood sample collection easier and reduces discomfort for the newborn.

B. A mummy restraint may not be necessary for a routine blood glucose test. The nurse can gently hold the newborn in place during the procedure without needing to fully restrain them.

C. Antiseptic solution is typically applied before the puncture to cleanse the area. After the procedure, gentle pressure and bandaging are more appropriate to stop bleeding.

D. Elevating the extremity is unnecessary for a newborn blood glucose test, as warming the area is more effective in promoting blood flow to the puncture site.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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