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
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.
Correct Answer is C
Explanation
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
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