A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
Fetal hypoxemia.
Cord compression.
Uteroplacental insufficiency.
Head compression.
The Correct Answer is D
Choice A rationale:
Fetal hypoxemia is associated with late decelerations in the fetal heart rate (FHR) tracing. It occurs when the fetus experiences a decreased supply of oxygen, typically due to placental insufficiency or maternal hypotension.
Choice B rationale:
Cord compression can lead to variable decelerations in the FHR tracing. It occurs when the umbilical cord is compressed, restricting blood flow to the fetus temporarily.
Choice C rationale:
Uteroplacental insufficiency causes late decelerations in the FHR tracing. It refers to an inadequate blood flow between the uterus and placenta, resulting in reduced oxygen supply to the fetus.
Choice D rationale:
Head compression is the correct answer for early decelerations in the FHR tracing. It happens during contractions when the fetal head is compressed by the maternal pelvis, leading to a temporary vagal response that slows the heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Restricting protein intake to less than 40 g/day is not appropriate for a client with preeclampsia with severe features. While protein restriction might be advised in some cases of preeclampsia, it is not a priority in severe cases where the focus is on managing potential complications.
Choice B rationale:
Initiating seizure precautions is essential in managing a client with preeclampsia with severe features. Preeclampsia can lead to eclampsia, a condition characterized by seizures. Seizure precautions involve implementing measures to prevent injury during a seizure, such as padding the side rails of the bed, ensuring a clear environment, and having emergency equipment readily available.
Choice C rationale:
Initiating an infusion of 0.9% sodium chloride at 150 ml/hr is not directly related to managing preeclampsia with severe features. Although intravenous fluids may be necessary in some cases, the priority in this situation is to prevent and manage potential seizures.
Choice D rationale:
Encouraging the client to ambulate twice per day is not appropriate for a client with preeclampsia with severe features. Bed rest is often recommended in severe cases to reduce stress on the cardiovascular system and decrease the risk of complications.
Correct Answer is A
Explanation
Choice A rationale:
The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.
Choice B rationale:
Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.
Choice C rationale:
Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.
Choice D rationale:
Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.
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