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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A: Late decelerations in the fetal heart rate are often associated with uteroplacental insufficiency, and one of the first interventions is to improve uterine blood flow by changing the client's position. Placing the client in a left lateral position can help relieve pressure on the vena cava and improve blood flow to the placenta and the baby.

Choice B: Administering oxygen is a correct intervention for late decelerations, but it should follow the position change. Oxygen administration helps increase oxygen levels in the maternal blood, which can improve fetal oxygenation.

Choice C: Applying a fetal scalp electrode can provide continuous fetal heart rate monitoring, but it does not address the immediate concern of late decelerations. Position change and oxygen administration should be the priority.

Choice D: Increasing the rate of the IV infusion might not have an immediate effect on resolving late decelerations. Position change and oxygen administration should be the initial interventions.

A. Contractions lasting 2 minutes and with no rest between contractions. B. Pressure on the perineum causing the client to have the desire to bear down. C. Discharge consisting of clear fluid from the vagina. D. Passage of a bloodtinged mucous plug.

Correct Answer is A

Explanation

Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further

evaluation and intervention.

Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.

Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.

Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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