A nurse is caring for a laboring patient with an external fetal monitor. The nurse notices late decelerations on the monitor strip.
What does the nurse interpret this as indicating?
Maternal bradycardia
Uteroplacental insufficiency
Umbilical cord compression
Fetal head compression
The Correct Answer is B
Choice A rationale
Maternal bradycardia refers to a slower than normal heart rate in the mother. While it can affect the baby’s health, it doesn’t cause late decelerations on the fetal monitor.
Choice B rationale
Late decelerations are caused by uteroplacental insufficiency, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus. This is why the nurse would interpret late decelerations as indicating uteroplacental insufficiency.
Choice C rationale
Umbilical cord compression can cause variable decelerations, not late decelerations. Variable decelerations are abrupt decreases in the fetal heart rate, typically associated with contractions, and they vary in onset, depth, and duration.
Choice D rationale
Fetal head compression typically causes early decelerations, not late decelerations. Early decelerations are a mirror image of the contraction and are generally not a concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Cervical dilation is a key sign that labor has begun. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a physical change that can be measured during a pelvic exam.
Choice B rationale
Pain above the umbilicus is not typically a sign of labor. During labor, contractions are usually felt as a tightening or cramping in the lower abdomen or back.
Choice C rationale
Brownish vaginal discharge can occur during pregnancy and is not necessarily a sign of labor. If the discharge is heavy, or accompanied by other symptoms such as pain or cramping, it should be evaluated by a healthcare provider.
Choice D rationale
The presence of amniotic fluid in the vaginal vault, also known as “water breaking,” can be a sign that labor is imminent. However, it does not confirm that labor has begun, as it can occur before the onset of contractions and cervical dilation.
Correct Answer is A
Explanation
Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.
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