A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
Accelerations.
Late decelerations.
Variable decelerations.
Early decelerations.
The Correct Answer is C
Choice A. Accelerations are normal responses that indicate the fetus is healthy and active. Accelerations occur when the fetal heart rate increases in response to stimuli. •
Choice B. Late decelerations are nonreassuring patterns that indicate fetal hypoxia due to placental insufficiency. Late decelerations occur when the placental blood flow decreases due to uterine contractions during labor, causing the fetal heart rate to decrease. •
Choice C. Variable decelerations are nonreassuring patterns that indicate fetal hypoxia due to umbilical cord compression. Variable decelerations occur when the umbilical cord is trapped by the cervical opening or the fetal body part, twisted, or knotted, causing the fetal oxygen supply to be impaired and the fetal heart rate to drop sharply. •
Choice D. Early decelerations are reassuring patterns that indicate a neural reflex due to fetal head compression. Early decelerations occur when the fetal head is compressed by uterine contractions during labor, causing the parasympathetic nervous system to be stimulated and the heart rate to decrease. The correct answer is C. Variable decelerations are the most common pattern that indicates a problem with the umbilical cord and requires urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Dehydration. A significantly indented anterior fontanelle in a newborn is most commonly a sign of dehydration.
Choice A reason:
Increased intracranial pressure: This statement is incorrect because increased intracranial pressure typically causes a bulging, not indented, fontanelle. Symptoms include irritability, vomiting, and a high-pitched cry.
Choice B reason:
Vernix caseosa: This statement is incorrect because vernix caseosa is a white, cheesy substance covering the skin of newborns, unrelated to fontanelle indentation. It serves as a protective layer for the baby’s skin.
Choice C reason:
Dehydration: This statement is correct. Dehydration in newborns can cause a sunken fontanelle due to the loss of fluid. Other signs include dry mouth, sunken eyes, and fewer wet diapers.
Choice D reason:
Cyanosis: This statement is incorrect because cyanosis refers to a bluish discoloration of the skin due to lack of oxygen, not related to fontanelle shape. It indicates issues with oxygenation or circulation.
Correct Answer is A
Explanation
Assist the client to turn onto her side. This is the correct answer because turning the client onto her side can improve blood flow to the placenta and increase fetal oxygenation. Hypotension is a common cause of decreased uteroplacental perfusion, which can lead to fetal distress and late decelerations on the fetal monitor. The nurse should also administer oxygen, increase IV fluids, and notify the provider. • Choice B reason:
Prepare for an immediate vaginal delivery. This is not the correct answer because there is no indication that the client is ready for delivery. The client has 6 cm of cervical dilation, which means she is still in the active phase of labor. The second stage of labor begins when the cervix is fully dilated (10 cm) and ends with delivery of the baby. Preparing for an immediate vaginal delivery would not address the cause of hypotension or improve fetal oxygenation. • Choice C reason:
Prepare for a cesarean birth. This is not the correct answer because there is no indication that the client needs a cesarean birth. A cesarean birth may be indicated if there are signs of fetal compromise, such as severe variable or late decelerations, or maternal complications, such as placenta previa or cord prolapse. However, these conditions are not present in this scenario. Preparing for a cesarean birth would not address the cause of hypotension or improve fetal oxygenation. • Choice D reason:
Assist the client to an upright position. This is not the correct answer because placing the client in an upright position can worsen hypotension and decrease uteroplacental perfusion. An upright position can increase pressure on the inferior vena cava and reduce venous return to the heart. This can lower cardiac output.
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