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
Choice A Reason:
Bilirubin 9 mg/dL is correct. A bilirubin level of 9 mg/dL in a newborn, especially at 4 hours old, is elevated and needs prompt attention. High bilirubin levels in newborns can be indicative of jaundice, and severe jaundice may lead to complications such as kernicterus. Monitoring and managing bilirubin levels are crucial to prevent potential neurologic damage.
Choice B Reason:
Hemoglobin 15 g/dL is incorrect. This hemoglobin level is within the normal range for a newborn. It's important to note that newborns often have higher hemoglobin levels shortly after birth, and this value is consistent with normal physiological ranges.
Choice C Reason:
Platelets 175,000/mm³ is incorrect. A platelet count of 175,000/mm³ is within the normal range for a newborn. There is no immediate concern based on this platelet count.
Choice D Reason:
Hematocrit 45% is incorrect. A hematocrit level of 45% is within the normal range for a newborn. Like hemoglobin, hematocrit levels can be higher in newborns shortly after birth, and this value falls within the expected range.
Correct Answer is B
Explanation
The correct answer is B. Turn the client onto her side.
A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.
B. Turning the client onto her side is the correct first action.
Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.
C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.
D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.
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