A nurse is caring for a client who is in labor and is receiving epidural analgesia.
Which of the following changes in the FHR should the nurse report to the provider?
Prolonged period of absent FHR variability.
FHR increase to 150/min.
FHR accelerations of 15/min for 15 seconds.
Early decelerations of the FHR.
The Correct Answer is A
Choice A rationale
A prolonged period of absent FHR variability is a critical finding that the nurse must report to the provider immediately. Absent variability indicates a significant lack of fetal well-being, potentially due to severe hypoxia, acidosis, or neurological compromise. It necessitates prompt intervention to prevent adverse outcomes.
Choice B rationale
An FHR increase to 150/min is within the normal fetal heart rate range, which typically falls between 110 and 160 beats per minute. This finding alone does not indicate a problem and would not require reporting to the provider, as it suggests adequate fetal oxygenation and an appropriately reactive fetus.
Choice C rationale
FHR accelerations of 15/min for 15 seconds are a positive sign of fetal well-being. Accelerations indicate an intact fetal nervous system and adequate oxygenation. They are a reassuring finding and suggest that the fetus is tolerating the labor process well, therefore not requiring reporting.
Choice D rationale
Early decelerations of the FHR are typically benign and do not require reporting to the provider. These decelerations are usually associated with head compression during contractions and are characterized by a gradual decrease in FHR that mirrors the contraction, indicating a physiological response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Premature newborns have immature respiratory and neurological systems, making them vulnerable to respiratory compromise and apnea in a car seat. A car seat test prior to discharge assesses their ability to maintain adequate oxygenation and heart rate while positioned in the car seat for a prolonged period, ensuring safety.
Choice B rationale
The retainer clip should be positioned at the level of the newborn's armpits, not the abdomen. Proper placement at the armpit level ensures that the harness straps are snug over the shoulders and chest, effectively restraining the infant and preventing ejection in the event of a collision, optimizing crash protection.
Choice C rationale
Newborns, especially premature ones, must always be placed in a rear-facing car seat in the back seat of the vehicle. Rear-facing provides optimal support for the newborn's fragile head, neck, and spine, distributing crash forces over the entire back and significantly reducing the risk of severe injuries in a collision.
Choice D rationale
The recommended angle for a rear-facing car seat is typically between 30 to 45 degrees, depending on the specific car seat model, not 60 degrees. This recline angle is crucial to prevent the newborn's head from falling forward and compromising their airway, which is particularly critical for a premature infant with underdeveloped neck control. .
Correct Answer is D
Explanation
Choice A rationale
The specific volume of formula for gavage feeding a newborn, such as 20 mL, depends on the newborn's weight, gestational age, and clinical condition. A blanket recommendation of 20 mL without this individualized assessment is inappropriate and could lead to over or underfeeding, impacting growth and gastrointestinal tolerance.
Choice B rationale
Placing a newborn in a supine position immediately after gavage feedings increases the risk of aspiration, especially for infants with immature swallowing reflexes or reflux. The newborn should be positioned on their right side or semi-Fowler's position to facilitate gastric emptying and minimize aspiration risk.
Choice C rationale
While cluster feeding (multiple feedings close together) is a natural pattern for some breastfed infants, for gavage feeding, regular, scheduled intervals are typically maintained to ensure consistent nutrient delivery and proper digestion, especially in newborns who are medically fragile. Cluster feeding is not a standard gavage feeding practice.
Choice D rationale
Nonnutritive sucking (e.g., pacifier use) during gavage feedings is crucial for promoting oral motor development and associating the feeling of fullness with sucking. This helps prevent oral aversion and prepares the newborn for eventual oral feeding, stimulating gastric secretions and improving digestion.
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