The RN interprets the following external fetal monitoring strip as:
Urgent: Maternal fever due to chorioamnionitis.
Non-urgent: Compression due to lack of amniotic fluid.
Urgent: Umbilical cord prolapse due to head not being engaged in the pelvic cavity.
Non-urgent: Progression of the fetal head through the vaginal canal.
The Correct Answer is C
Choice A rationale
Maternal fever due to chorioamnionitis would show maternal signs of infection and not directly indicate fetal heart rate changes typical of umbilical cord prolapse.
Choice B rationale
Compression due to lack of amniotic fluid (oligohydramnios) typically shows variable decelerations on the fetal monitoring strip but is not urgent without other symptoms.
Choice C rationale
Umbilical cord prolapse is an urgent condition where the umbilical cord slips ahead of the fetus and can be indicated by sudden severe variable decelerations on the fetal monitor strip, requiring immediate intervention.
Choice D rationale
Progression of the fetal head through the vaginal canal shows a gradual change in the fetal heart rate and not the sudden pattern seen with cord prolapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering epinephrine before the procedure is not standard practice to prevent hypotension associated with epidurals. Epinephrine is used in emergency situations to treat severe allergic reactions or cardiac arrest, not for preventing epidural-induced hypotension.
Choice B rationale
Positioning the client on her back prior to the procedure is not recommended, as it can exacerbate hypotension due to compression of the inferior vena cava by the gravid uterus. This position can decrease venous return to the heart and reduce cardiac output.
Choice C rationale
Having the patient eat a carbohydrate snack prior to the procedure is not a standard intervention to prevent hypotension during an epidural. Dietary intake does not directly prevent the vasodilatory effects of the epidural anesthesia.
Choice D rationale
Administering a bolus of 0.9% Normal saline IV fluid before the procedure is the correct intervention to prevent hypotension. Preloading with IV fluids increases intravascular volume, counteracting the vasodilation and potential drop in blood pressure caused by the epidural anesthesia. .
Correct Answer is D
Explanation
Choice A rationale
Administering oxytocin is not appropriate at this stage since the fetal head at a +5 station indicates imminent delivery.
Choice B rationale
Applying fundal pressure is not recommended and can cause complications such as uterine rupture or maternal injury.
Choice C rationale
Suctioning the mouth of the infant at the perineum should be done only after the head is delivered to clear airway obstructions.
Choice D rationale
Observing for the presence of a nuchal cord is crucial as it can cause complications during delivery, requiring immediate attention.
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