A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
Accelerations
Early decelerations
Late decelerations
Variable decelerations
The Correct Answer is D
The correct answer is D. Variable decelerations.
A. Accelerations in the fetal heart rate are generally considered reassuring. Accelerations are an indication of fetal well-being and are often seen in response to fetal movement.
B. Early decelerations are typically associated with head compression during contractions and are considered a normal response to the pressure on the fetal head.
C. Late decelerations are indicative of uteroplacental insufficiency.
Late decelerations occur after the peak of the contraction and are associated with inadequate oxygenation to the fetus. This pattern raises concerns about the baby's well-being.
D. Variable decelerations are associated with umbilical cord compression.
Variable decelerations are abrupt decreases in the fetal heart rate that vary in duration, depth, and timing. They often coincide with contractions and suggest compression or occlusion of the umbilical cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Insert a gloved hand into the vagina to relieve pressure on the cord.
A. Covering the cord with a sterile, moist saline dressing is a potential action, but relieving pressure on the cord takes precedence. This can be done by manually elevating the presenting part of the fetus off the cord.
B. Placing the client in a knee-chest position may be recommended after taking the immediate action of relieving pressure on the cord. Elevating the hips may help reduce cord compression.
C. Inserting a gloved hand into the vagina to relieve pressure on the cord is the priority action.
By manually lifting the presenting part off the cord, the nurse can help restore blood flow to the fetus and prevent umbilical cord compression.
D. Preparing the client for an immediate birth may be necessary, but the immediate action to relieve pressure on the cord should be performed first. The healthcare provider will determine the need for urgent delivery based on the clinical situation.
Correct Answer is B
Explanation
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
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