A nurse is providing care for a client who is in labor.
The nurse notes variable decelerations on the fetal heart rate monitor.
What could be the cause?
Umbilical cord compression.
Maternal hypotension.
Fetal sleep cycle.
Use of epidural anesthesia.
The Correct Answer is A
Choice A rationale:
Umbilical cord compression is the most common cause of variable decelerations. It occurs when the umbilical cord is
compressed, momentarily reducing blood flow to the fetus and causing a decrease in fetal heart rate.
Variable decelerations are characterized by their abrupt onset, variable duration, and unpredictable shape. They typically
recover quickly to the baseline fetal heart rate after the compression is relieved.
Several factors can contribute to umbilical cord compression, including:
Fetal movement: The fetus can sometimes move in a way that compresses the cord, especially during active labor.
Oligohydramnios (low amniotic fluid): With less amniotic fluid, there's less cushioning around the cord, making it more prone
to compression.
Nuchal cord (cord around the neck): If the cord is wrapped around the fetus's neck, it can become compressed during
contractions.
Short umbilical cord: A shorter cord has less slack, increasing the risk of compression.
Choice B rationale:
Maternal hypotension can cause fetal heart rate decelerations, but these typically present as late decelerations, not variable
decelerations. Late decelerations have a gradual onset, a uniform shape, and typically occur after the peak of a contraction.
Maternal hypotension can decrease placental blood flow, leading to fetal hypoxia (decreased oxygen supply). This hypoxia can
then trigger a decrease in fetal heart rate.
Choice C rationale:
The fetal sleep cycle does not typically cause variable decelerations in the fetal heart rate. During sleep, the fetal heart rate
may exhibit a decrease in baseline variability, but this is not the same as variable decelerations.
Choice D rationale:
The use of epidural anesthesia can sometimes cause a decrease in fetal heart rate variability, but it does not typically cause
variable decelerations. Epidural anesthesia can lead to maternal hypotension, which, as mentioned earlier, can cause late
decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: A fundus that is firm and 4 fingerbreadths above the umbilicus 24 hours postpartum indicates uterine atony or retained placental fragments. This finding is not typical and may require further medical evaluation to prevent postpartum hemorrhage.
Choice B rationale: A soft fundus 2 fingerbreadths below the umbilicus suggests uterine atony, which can lead to postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract effectively after childbirth.
Choice C rationale: A soft fundus to the right of the umbilicus may indicate a full bladder pushing the uterus to one side. It can interfere with uterine contractions and should be addressed by encouraging the client to empty their bladder.
Choice D rationale: A firm fundus at 1 fingerbreadth below the umbilicus is the expected finding 24 hours postpartum. It indicates that the uterus is contracting well and returning to its pre-pregnancy size, reducing the risk of postpartum hemorrhage.
Correct Answer is B
Explanation
Choice A rationale:
The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus
(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and
descend into the pelvic cavity, guided by the process known as involution.
Choice B rationale:
A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common
as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of
postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized
by high blood pressure and signs of damage to another organ system, often the kidneys.
Choice C rationale:
A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a
slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.
Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.