What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?

Spontaneous rupture of membranes.

Fetal head compression.

Umbilical cord compression.

Utero-placental insufficiency.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Spontaneous rupture of membranes (SROM) can sometimes be associated with variable decelerations due to potential cord compression if the presenting part is not well applied, but it is not the most likely cause of early decelerations. Early decelerations reflect a physiological response to fetal head compression.

Choice B rationale

Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.

Choice C rationale

Umbilical cord compression typically results in variable decelerations, which are abrupt decreases in FHR that are not necessarily associated with uterine contractions. The shape and timing of variable decelerations differ significantly from the gradual, consistent pattern of early decelerations.

Choice D rationale

Utero-placental insufficiency usually manifests as late decelerations, which are gradual decreases in FHR that begin after the peak of the contraction and recover after the contraction ends. This pattern indicates fetal hypoxia and is a concerning finding, distinct from early decelerations.

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Correct Answer is C

Explanation

Choice A rationale

Increasing ambulation is generally encouraged in the postpartum period to prevent complications like thrombophlebitis, but it does not address the potential cause of foul-smelling lochia. Foul odor is a key indicator of infection, and ambulation will not resolve an existing infection.

Choice B rationale

Increasing oral fluids is important for hydration in the postpartum period, but it will not directly address a foul-smelling odor in the lochia. While adequate hydration supports overall healing, it does not treat an infection. A foul odor strongly suggests a localized infectious process in the uterus.

Choice C rationale

Lochia that is red (rubra) is normal in the first few days postpartum. However, a foul-smelling odor is an abnormal finding and a significant indicator of a potential uterine infection, also known as endometritis or puerperal infection. Further assessment and intervention are required to identify and treat the infection.

Choice D rationale

Normal lochia progresses from rubra (red) to serosa (pinkish-brown) to alba (yellowish-white) over several weeks postpartum. Normal lochia should have a fleshy, not foul, odor. A foul smell is an abnormal finding that suggests an infectious process within the uterus and requires prompt attention.

A. Performing a cervical exam to assess dilation. B. Increasing the rate of intravenous fluids. C. Administering oxygen to the mother. D. Repositioning the mother to a knee-chest position.

Correct Answer is D

Explanation

Choice A rationale

While assessing cervical dilation is important for understanding the progress of labor, it is not the priority intervention in the case of umbilical cord prolapse. The immediate danger is fetal oxygen deprivation due to compression of the prolapsed cord. Delaying intervention to perform a cervical exam could worsen fetal hypoxia.

Choice B rationale

Increasing the rate of intravenous fluids might be indicated to support maternal blood pressure and placental perfusion, but it does not directly address the immediate problem of cord compression. The priority is to relieve pressure on the umbilical cord to restore fetal oxygen supply.

Choice C rationale

Administering oxygen to the mother is a helpful supportive measure to increase the oxygen available to the fetus. However, it does not directly relieve the compression on the umbilical cord, which is the immediate life-threatening situation for the fetus.

Choice D rationale

Repositioning the mother to a knee-chest position (or Trendelenburg) uses gravity to help relieve pressure on the prolapsed umbilical cord by moving the presenting part of the fetus away from the pelvis. This is the priority nursing intervention as it directly aims to improve fetal oxygenation by reducing cord compression until the fetus can be delivered. .

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What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the lochia on a 1-day postpartum patient.The nurse notes that the lochia is red and has a foul-smelling odor.The nurse determines that this assessment finding:

Correct Answer is C

Explanation

What is the priority nursing intervention for a patient experiencing umbilical cord prolapse during labor?

Correct Answer is D

Explanation

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