A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
Variable decelerations are a result of the administration of IV narcotic analgesics.
Variable decelerations are related to fetal head compression.
Variable decelerations are due to umbilical cord compression.
Variable decelerations are caused by uteroplacental insufficiency.
The Correct Answer is C
A) Variable decelerations are a result of the administration of IV narcotic analgesics: IV narcotic analgesics can cause changes in the fetal heart rate, but they are more commonly associated with early decelerations, not variable decelerations.
B) Variable decelerations are related to fetal head compression: Fetal head compression is associated with early decelerations, not variable decelerations.
C) Variable decelerations are due to umbilical cord compression: This is the correct answer.
Variable decelerations occur due to compression of the umbilical cord during contractions, leading to transient decreases in fetal blood flow and oxygenation.
D) Variable decelerations are caused by uteroplacental insufficiency: Uteroplacental insufficiency is associated with late decelerations, not variable decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: The client should not lie on her back during the NST because the supine position can compress the vena cava and reduce blood flow to the placenta and the baby. The NST is typically done with the client in a semireclined or left lateral position to ensure optimal blood flow to the baby.
Choice B: Monitoring the baby's heart rate is a correct statement and a standard part of the NST procedure.
Choice C: The duration mentioned (20 to 30 minutes) is accurate for the average NST timeframe.
Choice D: Scheduling the NST when the baby is usually active is also a correct statement, as fetal movement during the test is an important aspect of evaluating fetal wellbeing.
Correct Answer is B
Explanation
Choice A: Assessing the client's temperature is important, but it is not the priority immediately after an amniotomy. Fetal wellbeing takes precedence.
Choice B; After an amniotomy (artificial rupture of membranes), the priority nursing action is to assess the fetal heart rate and pattern. The procedure may cause changes in fetal heart rate and indicate fetal distress or cord compression, requiring immediate attention.
Choice C: Recording the color and consistency of fluid is relevant for documentation but does not address the immediate concern of fetal wellbeing.
Choice D: Evaluating the client for chills and uterine tenderness is not the priority after an amniotomy. Monitoring the fetal heart rate is crucial to detect any signs of distress.
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