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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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale:

Performing hand hygiene before and after voiding is crucial in preventing perineal infection. Hand hygiene is the most

effective way to prevent the spread of infections, including those that can infect the perineum.

Choice B rationale:

Cleaning the perineal area from front to back is a standard recommendation to prevent infection. This method ensures that

bacteria from the anal area are not spread to the vagina and urethra, which can cause urinary tract infections.

Choice C rationale:

Sitting on an inflatable donut is not typically recommended for the prevention of perineal infection. While it can provide

comfort for those with perineal pain, especially after childbirth, it does not directly contribute to the prevention of infection.

Choice D rationale:

Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, especially after a

vaginal birth. While it does not directly prevent infection, it can promote healing and comfort, which can indirectly help

prevent infection.

Choice E rationale:

Blotting the perineal area dry after voiding is another important step in preventing perineal infection. Keeping the area dry

prevents the growth of bacteria and other microbes that thrive in moist environments.

A. Increase the client’s fluid intake B. Check the consistency of the client’s uterine fundus C. Help the client use the bedpan to urinate D. Prepare to administer tocolytic medication

Correct Answer is B

Explanation

Choice A rationale:

Increasing fluid intake is not the priority action in this situation. While maintaining adequate hydration is important for

postpartum recovery, it does not directly address the immediate concern of excessive bleeding. Excessive fluid intake could

potentially worsen the bleeding by increasing blood volume and potentially increasing blood pressure.

Choice C rationale:

Helping the client use the bedpan to urinate is not the priority action in this case. While a full bladder can sometimes interfere

with uterine contraction and contribute to postpartum bleeding, it is not the most likely cause of the excessive bleeding in this

scenario. The client has already saturated two perineal pads in a short period, indicating a more significant bleeding issue that

needs to be addressed first.

Choice D rationale:

Preparing to administer tocolytic medication is not the appropriate action at this time. Tocolytic medications are used to stop

contractions, but they are not typically used to manage postpartum hemorrhage. In fact, tocolytics could potentially worsen

the bleeding by interfering with the natural mechanisms that help the uterus contract and stop bleeding after delivery.

Choice B rationale:

Checking the consistency of the client's uterine fundus is the priority action in this situation. The most common cause of

postpartum hemorrhage is uterine atony, which means the uterus is not contracting effectively to clamp down on the blood

vessels where the placenta was attached. A soft, boggy fundus is a sign of uterine atony. By assessing the fundus, the nurse can

quickly determine if uterine atony is the likely cause of the bleeding and take appropriate interventions to manage it.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a client 2 hours following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-minute period.Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postpartum following a cesarean birth.To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client’s care?

A nurse is performing an assessment on a postpartum patient. The uterus is found to be displaced to the right.Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min.Which of the following actions should the nurse take first?

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia.Which of the following responses should the nurse make?

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A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

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?