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 C
Explanation
Choice A rationale
The critical congenital heart disease (CCHD) screening is typically performed when the newborn is between 24 and 48 hours of age, or just prior to discharge if that occurs earlier. Performing the test too early, such as between 6 and 12 hours, might yield false negative results due to the persistence of transitional circulation.
Choice B rationale
The results of the CCHD screening are typically available immediately, or within a few minutes, as it involves pulse oximetry readings. There is no waiting period of 1 to 2 weeks for the results, allowing for prompt identification and management of potential cardiac defects, preventing delays in care.
Choice C rationale
The CCHD screening specifically compares the oxygen saturation in the newborn's right hand (pre-ductal) and either foot (post-ductal). A significant difference between these two readings can indicate a shunt or obstruction within the heart or great vessels, suggesting a potential critical congenital heart defect.
Choice D rationale
Collecting a blood sample from the newborn's heel is the procedure for the newborn metabolic screening, which screens for various genetic and metabolic disorders, not the critical congenital heart disease screening. The CCHD screening is a non-invasive test performed using pulse oximetry.
Correct Answer is D
Explanation
Choice A rationale
Hydrocodone is an opioid analgesic, but it is typically used for moderate to severe pain and is not commonly administered as a primary agent for severe active labor pain due to its slower onset and potential for more pronounced maternal and neonatal respiratory depression compared to other rapid-acting opioids.
Choice B rationale
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) primarily used for mild to moderate pain and inflammation. It is generally not effective enough for severe labor pain and is contraindicated in late pregnancy due to potential adverse effects on fetal circulation, such as premature closure of the ductus arteriosus.
Choice C rationale
Naloxone hydrochloride is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering naloxone during active labor would reverse the effects of any pain medication given, exacerbating the client's pain and potentially precipitating opioid withdrawal symptoms, thus it is not an appropriate pain management strategy.
Choice D rationale
Fentanyl citrate is a potent, rapid-acting synthetic opioid analgesic commonly used for severe pain during active labor. Its quick onset and short duration of action make it suitable for intermittent administration, allowing for effective pain relief with a lower risk of prolonged neonatal respiratory depression compared to longer-acting opioids.
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