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.
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Related Questions
Correct Answer is D
Explanation
Choice A: Pain above the umbilicus may be associated with various conditions during pregnancy, but it is not a definitive sign of labor.
Choice B: The presence of amniotic fluid in the vaginal vault (rupture of membranes or "water breaking") can be a sign of labor, but it is not the most specific indicator.
Choice C: Brownish vaginal discharge may indicate the passage of old blood or "bloody show," which can be a sign of impending labor. However, it is not as reliable as cervical dilation.
Choice D: Cervical dilation is one of the most definitive signs of labor. As the cervix opens and thins (effaces), it allows for the baby's passage through the birth canal. Cervical dilation is an essential indicator of active labor.
Correct Answer is A
Explanation
Choice A: The client's symptoms of lightheadedness and tingling fingers indicate that she may be hyperventilating, which can occur when patternpaced breathing is too rapid. Breathing into a paper bag can help the client rebreathe some of the exhaled carbon dioxide, which can help correct the respiratory alkalosis caused by hyperventilation.
Choice B: Administering oxygen via nasal cannula may not address the underlying issue of hyperventilation. It is more appropriate to assist the client in slowing down her breathing pattern.
Choice C: Tucking the chin to the chest is not relevant to the client's symptoms of hyperventilation.
Choice D: Instructing the client to increase her respiratory rate would exacerbate the hyperventilation, leading to more symptoms of respiratory alkalosis.
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