A nurse is caring for a 26-year-old female client in the labor and delivery unit. The client is gravida 2, para 1, term 1, living 1, and is admitted with cervical dilation of 4 cm, 70% effacement, and -1 station. The pregnancy has been uncomplicated.
Exhibits:
The nurse reviews the client data. Drag the word choices to complete the sentence.
Abnormal FHR patterns can result in
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"E"}
Acidemia: Acidemia refers to an abnormal acidity in the blood (pH < 7.35). Prolonged abnormal FHR patterns can indicate insufficient oxygen delivery to the fetus, leading to anaerobic metabolism and the production of lactic acid, causing acidemia. The normal fetal pH is around 7.30-7.35.
Hypoxemia: Hypoxemia is a reduced level of oxygen in the blood. Abnormal FHR patterns may signal that the fetus is not receiving adequate oxygen, potentially due to cord compression, placental insufficiency, or other factors affecting oxygen transfer. Normal oxygen saturation for a fetus is generally around 30-70%.
Hypoxia: Hypoxia is a condition where there is insufficient oxygen available to meet the metabolic needs of the fetus. Abnormal FHR patterns can indicate ongoing or impending hypoxia, which can lead to severe fetal distress and compromise. It is crucial to monitor and address such conditions promptly.
Rationale for Incorrect Answers:
Hypoglycemia: Hypoglycemia refers to low blood glucose levels (typically < 45 mg/dL in newborns). Abnormal FHR patterns are not directly associated with changes in glucose metabolism. Rather, hypoglycemia in neonates is often related to maternal diabetes, prematurity, or other metabolic disturbances.
Meconium Stool: Meconium-stained amniotic fluid is a possible indicator of fetal distress but is not a direct result of abnormal FHR patterns. Meconium passage may be associated with post-term pregnancy, fetal hypoxia, or other factors, but the direct consequences of abnormal FHR patterns are more specifically related to oxygenation and acid-base status.
Maternal Hypotension: Maternal hypotension, or low blood pressure (typically < 90/60 mm Hg), is a maternal condition that can affect fetal well-being if severe and prolonged. However, it is not a direct result of abnormal FHR patterns. Instead, maternal hypotension can contribute to abnormal FHR by impairing uteroplacental perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Caput succedaneum is a benign swelling of the soft tissues of the scalp that crosses suture lines and does not require drainage.
Choice B rationale
Cephalhematoma is a collection of blood between the skull and periosteum that does not cross suture lines; it may contribute to jaundice as it is reabsorbed by the body.
Choice C rationale
While cephalhematoma usually resolves without intervention, it is important to monitor for potential complications, including jaundice, due to the breakdown of red blood cells.
Choice D rationale
Caput succedaneum typically resolves on its own without intervention, as the fluid is gradually absorbed by the body over time.
Correct Answer is ["B","D","F","G"]
Explanation
Choice B rationale
Proteinuria indicates preeclampsia, which involves increased glomerular permeability due to endothelial damage. Normal protein in urine is <150 mg/day.
Choice F rationale
Hyperreflexia can be a sign of CNS irritability in preeclampsia, which can lead to seizures if untreated. Normal reflexes are 2+.
Choice G rationale
Assessing lung sounds is critical as pulmonary edema can develop in severe preeclampsia due to increased capillary permeability. Normal breath sounds are clear and equal bilaterally.
Choice D rationale
A vision test helps assess for visual disturbances due to cerebral edema or optic nerve involvement in preeclampsia. Normal visual acuity is 20/20.
Choice A rationale
Hemoglobin assessment could indicate anemia, but it does not specifically address preeclampsia symptoms. Normal hemoglobin is 12-16 g/dL for women.
Choice C rationale
Perineal assessment checks for infection or hematoma but is less likely to explain systemic symptoms like headache and dizziness.
Choice E rationale
Skin turgor assesses hydration status, but dehydration is less likely to explain severe headache, dizziness, and visual disturbances. Normal skin turgor is immediate recoil.
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