A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
Umbilical cord compression
Uteroplacental insufficiency
Fetal head compression
Material bradycardia
The Correct Answer is B
The correct answer is B. Uteroplacental insufficiency.
A. Umbilical cord compression is more commonly associated with variable decelerations, not late decelerations. Variable decelerations are characterized by abrupt decreases and increases in the fetal heart rate.
B. Late decelerations are indicative of uteroplacental insufficiency.
Uteroplacental insufficiency refers to a decrease in blood flow and oxygen supply from the mother to the fetus. Late decelerations occur after the peak of the contraction and may suggest inadequate oxygenation to the fetus.
C. Fetal head compression is associated with early decelerations, not late decelerations. Early decelerations typically coincide with the contractions and are considered a normal response to head compression during contractions.
D. Maternal bradycardia is not typically associated with late decelerations. Late decelerations are primarily related to issues with oxygenation and blood flow to the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Slow-paced breathing
A. Slow-paced breathing is a nonpharmacological comfort measure that involves taking slow, deep breaths to promote relaxation and reduce anxiety. It can be an effective technique for managing pain during contractions.
B. Biofeedback involves the use of electronic monitoring to provide feedback about physiological processes, and it is not typically used as a primary nonpharmacological comfort measure for labor pain.
C. Self-hypnosis is a relaxation technique that involves guided imagery and focused concentration to promote relaxation and reduce pain. However, it may require some previous knowledge or practice, and in the context of this scenario, slow-paced breathing may be a more immediate and accessible option.
D. Acupuncture involves the insertion of needles into specific points on the body to stimulate energy flow. While acupuncture can be effective for pain management, it may not be readily available in all labor settings, and slow-paced breathing is a more universally applicable option.
Correct Answer is D
Explanation
A. Resting tone of 15 mmHg:A resting tone of 15 mmHg is generally acceptable and indicates normal uterine resting pressure, which should be between 5 and 20 mmHg.
B. Frequency of every two minutes. A frequency of every two minutes can be acceptable during labor, especially if the contractions are not too long or intense. The key consideration is the duration and intensity of the contractions.
C. Intensity of 60 to 90 mmHg: This intensity is typically acceptable for labor induction and signifies effective contractions. There’s no indication to stop oxytocin based solely on this intensity range.
D. Duration of 90 to 120 seconds:A contraction lasting 90 to 120 seconds is concerning and indicates potential uterine hyperstimulation, warranting the discontinuation of oxytocin to protect both the mother and fetus from adverse effects.
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