The nurse caring for a client in labor observes the external fetal monitor tracing showing that there are accelerations with moderate variability.
Which of the following actions is most appropriate?
Document the findings and tell the mother that the monitor indicates fetal well-being.
Call the midwife or doctor right away to tell them.
Take the mother’s vital signs and tell her that bed rest is required to conserve oxygen.
Reposition the mother and check the monitor for changes in the fetal tracing.
The Correct Answer is A
Choice A rationale
Accelerations with moderate variability indicate fetal well-being and responsiveness to the uterine environment, requiring documentation of normal findings and reassurance to the mother.
Choice B rationale
There is no need to immediately call the midwife or doctor, as accelerations with moderate variability are positive indicators of fetal health and do not suggest any issues.
Choice C rationale
Taking maternal vital signs and advising bed rest is unnecessary because the observed accelerations and variability show that the fetus is not experiencing distress, negating the need for such interventions.
Choice D rationale
Repositioning the mother and checking the monitor for changes is unnecessary, given that accelerations with moderate variability already indicate a well-oxygenated and responsive fetus, not requiring any adjustments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Meconium is produced by the fetal intestines. The intestines start to form meconium around the 16th week of gestation. Meconium is composed of shed cells, mucus, amniotic fluid, bile, and lanugo.
Choice B rationale
The placenta does not produce meconium. Its primary functions include nutrient transfer, gas exchange, and waste elimination, but it does not have the structures necessary for the production of meconium.
Choice C rationale
Amniotic fluid does not produce meconium. Amniotic fluid surrounds and protects the fetus but does not contain the components needed to create meconium. Instead, the fetus swallows and then excretes it into the intestines.
Choice D rationale
Fetal kidneys are responsible for filtering waste and producing urine, but they do not produce meconium. The production of meconium is a function of the intestines, not the kidneys.
Correct Answer is B
Explanation
Choice A rationale
Continuing the same comfort methods that have become ineffective is unlikely to help the client and may increase frustration. Adaptation to the client’s changing needs is necessary for effective care.
Choice B rationale
Choosing an alternate method of comfort promotion is appropriate as it addresses the client's current needs and helps to alleviate frustration. Alternate methods might include massage, repositioning, or hydrotherapy.
Choice C rationale
Asking the support person to leave the room may not address the client's comfort needs and could decrease her emotional support, potentially increasing stress and frustration rather than providing relief.
Choice D rationale
Telling the client to relax more is not supportive and does not provide a new strategy to promote comfort. It may be dismissive and can increase the client’s frustration and anxiety during labor.
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