A nurse is observing the internal fetal monitor readings of a laboring client.The fetal heart rate is between 130 and 138 beats per minute, with moderate beat-to-beat variability.
How should the nurse interpret this finding?
Insufficient perfusion of the placenta.
Sufficient perfusion and circulation of the fetus.
Maternal hypoxia.
Fetal hypoxia.
The Correct Answer is B
he correct answer is choice B. Sufficient perfusion and circulation of the fetus. This is because the fetal heart rate is within the normal range of 110 to 160 beats per minute, and there is moderate beat-to-beat variability, which indicates a healthy nervous system.
Choice A is wrong because insufficient perfusion of the placenta would cause fetal distress and abnormal fetal heart rate patterns, such as late decelerations or minimal variability.
Choice C is wrong because maternal hypoxia would not directly affect the fetal heart rate, unless it leads to placental insufficiency or uterine hyperstimulation.
Choice D is wrong because fetal hypoxia would cause signs of fetal distress, such as tachycardia, bradycardia, or absent variability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Apply ice to her perineal area.This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth.Ice should be applied for the first 24 to 48 hours after delivery.
Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy.They can increase blood flow and inflammation in the area, and may interfere with healing.
Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort.It can also affect blood circulation and drainage in the area.
Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours.Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later.However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.
Normal ranges for episiotomy healing are:
• Stitches dissolve within 2 to 4 weeks
• Pain and swelling subside within a few days to a week
• Wound heals completely within 4 to 6 weeks
Correct Answer is D
Explanation
The correct answer is choice D: “This test is used to identify fetal abnormalities.” Alpha-fetoprotein (AFP) is a protein produced by the fetus that can be measured in the mother’s blood.
Abnormal levels of AFP may indicate a problem with the development of the baby’s brain, spine, or other organs.
This test is usually done between 15 and 20 weeks of gestation.
Choice A is wrong because AFP does not measure the baby’s maturity.
It is not related to the gestational age or the lung development of the fetus.
Choice B is wrong because AFP is not a routine test for all pregnant women over thirty years of age.
It is an optional screening test that may be offered to women who have a higher risk of having a baby with a birth defect, such as those who have a family history, a previous affected pregnancy, or certain ethnic backgrounds.
Choice C is wrong because AFP is not recommended for people with a history of infertility.
It does not assess the fertility status of the mother or the father.
It only measures the level of a fetal protein in the mother’s blood.
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