A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
Uteroplacental insufficiency.
Umbilical cord compression.
Maternal bradycardia.
Fetal head compression.
The Correct Answer is A
Choice A reason:
Uteroplacental insufficiency is a condition where the placenta cannot deliver enough oxygen and nutrients to the fetus. This can cause fetal hypoxia and distress, which can be detected by late decelerations on the fetal heart rate monitor. Late decelerations are defined as a decrease in the fetal heart rate that begins after the peak of the contraction and returns to baseline after the contraction ends. This indicates that the fetus is not tolerating the reduced blood flow during the contractions and needs immediate intervention. • Choice B reason:
Umbilical cord compression is a condition where the umbilical cord is squeezed or twisted, reducing the blood flow and oxygen to the fetus. This can cause variable decelerations on the fetal heart rate monitor. Variable decelerations are defined as a decrease in the fetal heart rate that varies in timing, shape, and duration, and may or may not be associated with contractions. This indicates that the fetus is experiencing intermittent or sustained cord compression and may need repositioning or other interventions. • Choice C reason:
Maternal bradycardia is a condition where the mother's heart rate is slower than normal, usually less than 60 beats per minute. This can cause reduced blood flow and oxygen to the placenta and the fetus, but it does not cause late decelerations on the fetal heart rate monitor. Maternal bradycardia can be caused by various factors, such as medications, hypothermia, hypothyroidism, or vagal stimulation. It may need treatment depending on the cause and severity. • Choice D reason:
Fetal head compression is a condition where the fetal head is pressed against the cervix or the pelvic floor during labor, stimulating the vagus nerve and slowing down the fetal heart rate. This can cause early decelerations on the fetal heart rate monitor. Early decelerations are defined as a decrease in the fetal heart rate that begins with the onset of the contraction and returns to baseline with the end of the contraction. This indicates that the fetus is descending in the birth canal and is usually a normal and benign finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
Choice B reason:
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
Choice C reason:
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
Choice D reason:
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
Correct Answer is A
Explanation
Choice A reason:
The nurse's priority in this situation is the client's blood pressure of 80/56 mm Hg. Opioid epidural analgesia can cause a drop in blood pressure, known as hypotension. Hypotension can be a significant concern during labor, as it may reduce blood flow to the placenta and compromise the baby's well-being. Therefore, it is crucial for the nurse to address this finding promptly to prevent any adverse effects on both the mother and the baby. The nurse may need to administer intravenous fluids, adjust the dosage of the opioid medication, or take other appropriate actions to raise the blood pressure to a safer level.
Choice B reason:
While profuse itching (choice B) can be a common side effect of opioids, it is not the nurse's priority in this situation. Itching, also known as pruritus, can be managed with antihistamines or other supportive measures, but it is not an immediate threat to the client's well-being.
Choice C reason:
The client reporting weakness of the lower extremities (choice C) is an expected side effect of epidural analgesia. Epidurals can cause temporary paralysis or weakness in the lower body due to the local anesthetic's effects on the nerves. While it's essential to monitor and support the client during this time, it is not the priority over the potentially dangerous drop in blood pressure.
Choice D reason:
A temperature of 38.2°C (100.8 F) (choice D) may indicate a fever, but it is not the nurse's priority in this specific situation of opioid epidural analgesia during labor. Fever during labor could have various causes, and the nurse should investigate and manage it appropriately. However, addressing the client's blood pressure takes precedence, as hypotension can have immediate and significant consequences.
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