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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Implementing seizure precautions is not necessary based on these lab results. Seizure precautions are typically implemented for patients with a known seizure disorder or those who are at risk for seizures, such as patients with severe preeclampsia or eclampsia, neither of which can be diagnosed based on these lab results.
Choice B rationale
Checking deep tendon reflexes every hour is not indicated based on these lab results. This action is typically taken for patients with altered neurological status or those receiving certain medications that can affect muscle tone.
Choice C rationale
Reviewing the daily logs of the patient is a good practice in general to monitor the patient’s progress and response to treatment. However, it is not a specific action that should be taken based on these lab results.
Choice D rationale
Obtaining a prescription for methyldopa is not indicated based on these lab results.
Methyldopa is a medication used to treat high blood pressure, and there is no indication from these lab results that the patient has high blood pressure.
Correct Answer is A
Explanation
The priority finding for a nurse caring for a client receiving opioid epidural analgesia during labor would be a blood pressure of 80/56 mm Hg. This could indicate hypotension, a known side effect of epidural analgesia. Hypotension can lead to decreased perfusion to vital organs, including the placenta, potentially compromising the fetus. Immediate interventions might include positioning the patient on her side, increasing the rate of IV fluids, and notifying the healthcare provider.
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