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 D
Explanation
Braxton Hicks contractions are irregular, painless uterine contractions that occur throughout pregnancy, but are more noticeable in the third trimester.They do not indicate labor, but rather help in softening and ripening the cervix.
Choice A is wrong because the patient does not need to time the contractions unless they become regular, painful, and closer together, which are signs of true labor.
Choice B is wrong because documenting fetal activity daily is not related to Braxton Hicks contractions.Fetal activity is monitored to assess fetal well-being and detect any signs of fetal distress.
Choice C is wrong because losing the mucus plug is also not related to Braxton Hicks contractions.The mucus plug is a thick plug of mucus that seals the cervical canal during pregnancy and may be expelled before or during labor.
Correct Answer is C
Explanation
The correct answer is choice C. Ask what the patient ate and drank within the last day or two.This is because the nurse needs to assess the patient’s current nutritional status and eating habits before providing any education or advice.The nurse can then tailor the counseling to the patient’s specific needs and preferences.
Choice A is wrong because it is not the first action that the nurse should take.While it is important to explain the importance of adequate nutrition for the patient’s own growth and development, this should be done after assessing the patient’s current situation.
Choice B is wrong because it is not the first action that the nurse should take.While it is important to explain the relationship between the patient’s eating habits and fetal development, this should be done after assessing the patient’s current situation.
Choice D is wrong because it is not the first action that the nurse should take.While it is important to discuss with the patient the basic nutritional requirements of pregnancy, this should be done after assessing the patient’s current situation.
The normal ranges for nutritional intake during pregnancy vary depending on the age, weight, activity level, and health status of the patient.
However, some general guidelines are:
• Increase calorie intake by about 300 calories per day
• Increase protein intake by about 25 grams per day
• Increase calcium intake by about 1000 milligrams per day
• Increase iron intake by about 27 milligrams per day
• Increase folic acid intake by about 600 micrograms per day
• Increase fluid intake by about 8 to 10 cups per day
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