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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Stimulate the infant to cry. While stimulating the infant to cry is a common practice to assess the newborn's respiratory function, it is not the first action the nurse should perform in this situation. The newborn may cry spontaneously or may require other interventions, such as clearing the respiratory tract, before crying.
Choice B rationale:
Clear the respiratory tract. Clearing the respiratory tract is the priority action in this scenario. It ensures that the airway is open and allows the infant to breathe effectively. This is crucial because newborns are at higher risk of respiratory distress after birth, and prompt action can prevent complications.
Choice C rationale:
Dry the infant off and cover the head. Drying the infant off and covering the head are important steps to prevent heat loss and maintain the newborn's body temperature. However, these actions can be delayed briefly until the respiratory tract is cleared, as the immediate focus should be on ensuring the infant's ability to breathe.
Choice D rationale:
Clamp the umbilical cord. Clamping the umbilical cord is a standard procedure after birth to prevent bleeding and infection. However, it is not the priority in this situation. The first step should be to ensure the newborn's airway is clear and they can breathe adequately.
Correct Answer is A
Explanation
The correct answer is choice A: Respiratory rate of 16/min.
Choice A rationale:
A respiratory rate of 16/min is within the normal range for adults, which is typically between 12 to 20 breaths per minute. In the context of severe preeclampsia, maintaining a normal respiratory rate is crucial when administering magnesium sulfate IV, as one of the signs of magnesium toxicity is respiratory depression. Therefore, a respiratory rate of 16/min indicates that the client is not experiencing respiratory depression and it is safe to continue the magnesium sulfate infusion.
Choice B rationale:
A heart rate of 60/min is at the lower end of the normal range, which is 60 to 100 beats per minute for adults. However, bradycardia or a low heart rate can be a sign of magnesium sulfate toxicity, especially if accompanied by other symptoms such as hypotension or altered mental status. Without additional context, a heart rate of 60/min alone does not necessarily indicate it is unsafe to continue the infusion, but it would require further assessment.
Choice C rationale:
A urine output of 50 mL in 4 hours is significantly below the expected minimum of 30 mL/hour for adults. Adequate urine output is an important indicator of kidney function and is essential for the excretion of magnesium. In the case of magnesium sulfate infusion for severe preeclampsia, a low urine output could indicate renal insufficiency and an increased risk of magnesium toxicity. Therefore, a urine output of 50 mL in 4 hours is a contraindication for continuing the infusion without further evaluation.
Choice D rationale:
Diminished deep-tendon reflexes can be a sign of magnesium toxicity. Deep-tendon reflexes are assessed to monitor for signs of magnesium overdose during infusion, as magnesium acts as a central nervous system depressant at high levels. If deep-tendon reflexes are diminished, it may suggest that the serum magnesium levels are too high, and the infusion should be paused or discontinued to prevent further toxicity.
In summary, the only finding that clearly indicates it is safe to continue the magnesium sulfate infusion is a normal respiratory rate, as provided in choice A. The other options either require further assessment or are indicators of potential magnesium toxicity.
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