The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?
Variable decelerations.
Late decelerations.
No decelerations.
Early decelerations.
The Correct Answer is B
Choice A rationale
Variable decelerations are abrupt decreases in fetal heart rate, unrelated to contractions and typically caused by umbilical cord compression. The described pattern does not match these characteristics.
Choice B rationale
Late decelerations occur when there is a gradual decrease in fetal heart rate starting after the contraction begins and returning to baseline after the contraction ends, often indicating utero-placental insufficiency.
Choice C rationale
No decelerations are present when there are no decreases in fetal heart rate. The scenario described includes a specific pattern of decelerations, making this choice incorrect.
Choice D rationale
Early decelerations are a gradual decrease in fetal heart rate that mirrors the contraction pattern, often caused by head compression during contractions. The pattern described does not fit early decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.
Choice B rationale
Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.
Choice C rationale
Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.
Choice D rationale
Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.
Correct Answer is C
Explanation
Choice A rationale
Administering acetaminophen is not indicated as the temperature of 100.4° F (38° C) is within the normal postpartum range, often due to dehydration or breast engorgement. Acetaminophen should be used cautiously and only if necessary.
Choice B rationale
Assessing perineum for excessive lochia is unnecessary here, as the current vital signs do not indicate hemorrhage. Normal postpartum bleeding gradually decreases in amount and should be monitored accordingly but not prompted by these vitals.
Choice C rationale
Documentation of vital signs is essential to maintain accurate medical records and track any changes in the patient's condition. Accurate records help in identifying trends and making informed decisions about patient care.
Choice D rationale
Reporting a heart rate of 58 beats/minute is unnecessary because bradycardia can be normal in postpartum women, especially if they have good cardiovascular fitness. It is important to monitor for other symptoms before taking further action.
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