A nurse is caring for a client in the first stage of labor who is undergoing external fetal monitoring and receiving IV fluids. The nurse observes variable decelerations in the fetal heart rate on the monitor strip.
Which of the following is the correct interpretation of this finding
Variable decelerations are related to fetal head compression.
Variable decelerations are due to umbilical cord compression.
Variable decelerations are caused by uteroplacental insufficiency.
Variable decelerations are a result of the administration of narcotic analgesics.
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale
Variable decelerations are not related to fetal head compression. Fetal head compression typically results in early decelerations, not variable ones.
Choice B rationale
Variable decelerations are indeed due to umbilical cord compression. They are quick decreases in fetal heart rate that vary with uterine contractions. This can be a sign that the baby’s blood flow is reduced if variable decelerations happen over and over.
Choice C rationale
Uteroplacental insufficiency typically results in late decelerations, not variable ones. Late decelerations are a sign of fetal hypoxia and are associated with uteroplacental insufficiency.
Choice D rationale
While certain medications can affect the fetal heart rate, variable decelerations are not typically a result of the administration of narcotic analgesics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Vaginal discharge is common during pregnancy due to the increased production of estrogen and greater blood flow to the pelvic area. It is not typically a sign of preeclampsia.
Choice B rationale
Elevated blood pressure is a primary symptom of preeclampsia. If a pregnant client has high blood pressure, it should indicate to the nurse that the client requires further evaluation for this disorder.
Choice C rationale
Joint pain is not typically a symptom of preeclampsia. It could be related to other conditions or simply a result of the physical changes of pregnancy.
Choice D rationale
Increased urine output is not typically associated with preeclampsia. In fact, decreased urine output could potentially be a sign of kidney problems related to preeclampsia.
Correct Answer is D
Explanation
A. In a cephalic (head-down) presentation, fetal heart tones are typically heard below the umbilicus.
B. A posterior position refers to the fetal back facing the mother's back, but it does not affect the heart tone location significantly.
C. A transverse lie would place the fetal heart tones at the lateral sides of the abdomen, not above the umbilicus.
D. In a frank breech position (buttocks presenting first), fetal heart tones are usually heard above the umbilicus, as the fetal head is positioned in the upper uterus.
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