A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

Fetal head compression.

Umbilical cord compression.

Maternal opioid administration.

Uteroplacental insufficiency.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.
Choice B rationale:
Umbilical cord compression is a known cause of variable decelerations in the fetal heart rate. When the umbilical cord is compressed, it can temporarily disrupt blood flow and oxygen supply to the fetus, leading to decelerations. Variable decelerations often appear as abrupt, sharp drops in the fetal heart rate and are typically characterized by their unpredictable
nature.
Choice C rationale:
Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.
Choice D rationale:
Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which can lead to late decelerations in the fetal heart rate, not variable decelerations.

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Correct Answer is B

Explanation

Choice A rationale:
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.

Choice B rationale:
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.

Choice C rationale:
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.

Choice D rationale:
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.

A. Preterm labor. B. Infection. C. Profound bleeding. D. Rupture of the fetal membranes.

Correct Answer is C

Explanation

Choice A rationale:

Preterm labor. Performing a pelvic examination in a client with placenta previa can potentially trigger uterine contractions, leading to preterm labor. Manipulating the cervix during the examination may stimulate the release of hormones that could initiate labor, putting both the mother and the baby at risk.

Choice B rationale:

Infection. While infection is a valid concern in any medical procedure, it is not the primary rationale for avoiding a pelvic examination in a client with placenta previa. The primary concern is the risk of severe bleeding caused by the disruption of the placenta's attachment to the uterine wall.

Choice C rationale:

Profound bleeding. The primary rationale to avoid a pelvic examination in a client with placenta previa is the risk of profound bleeding. Placenta previa occurs when the placenta covers part or all of the cervix, and it is at risk of being damaged or detached during a pelvic exam. This can lead to life-threatening hemorrhage for both the mother and the baby.

Choice D rationale:

Rupture of the fetal membranes. While this complication is possible during a pelvic examination, it is not the primary rationale to avoid the procedure in a client with placenta previa. The main concern, as mentioned before, is the risk of severe bleeding that can occur due to placental disruption.

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A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary rationale the nurse should avoid performing a pelvic examination?

Correct Answer is C

Explanation

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