When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?

Increase in baseline variability.

Non-periodic accelerations.

Early decelerations.

Variable decelerations.

Answer and Explanation

The Correct Answer is D

Choice A rationale

An increase in baseline variability is generally considered a reassuring sign of fetal well-being, indicating a responsive central nervous system and adequate oxygenation. While important to monitor, it is not a specific periodic pattern to observe immediately following membrane rupture due to potential cord compression. Normal baseline variability ranges from 6 to 25 beats per minute.

Choice B rationale

Non-periodic accelerations are abrupt increases in fetal heart rate above the baseline, typically lasting less than 30 seconds. They are usually a reassuring sign, often occurring with fetal movement or stimulation. While their presence is noted, they are not the primary periodic pattern to observe immediately after membrane rupture for potential complications.

Choice C rationale

Early decelerations are gradual decreases in fetal heart rate that mirror the uterine contractions. They are thought to be caused by fetal head compression and are generally considered benign. While their presence is documented, they are not the most concerning pattern immediately after membrane rupture, which raises the risk of cord issues.

Choice D rationale

Variable decelerations are abrupt decreases in fetal heart rate that are variable in timing and shape in relation to uterine contractions. They are often caused by umbilical cord compression, which is a significant risk factor immediately following the rupture of membranes, as the fluid cushion around the cord is reduced. Prompt identification is crucial for intervention.

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Correct Answer is D

Explanation

Choice A rationale

While addressing the client's pain is important, the priority action should be to assess the underlying cause of the concerning vital signs before offering pain medication.

Choice B rationale

Positioning the client with one hip elevated is a measure used to relieve potential vena cava compression, but the low blood pressure warrants immediate attention and further evaluation before implementing this intervention.

Choice C rationale

Having the client void may be a helpful intervention in some labor situations, but the combination of a low maternal blood pressure and a high maternal heart rate requires immediate notification of the provider.

Choice D rationale

The client's low blood pressure (82/54 mm Hg) and elevated maternal heart rate (128/min) in the presence of contractions with a duration of 1 minute and a frequency of 3 minutes are concerning findings that warrant immediate notification of the provider for further evaluation and management. These vital signs could indicate maternal hypovolemia, dehydration, or other complications. .

A. "Because blood pressure often increases early in the second trimester of pregnancy.”. B. "You are at an increased risk for high blood pressure since you've had several pregnancies.”. C. "Your age is a risk factor for developing high blood pressure during pregnancy.”. D. "No need to worry about that, let's talk about how you're feeling.”.

Correct Answer is C

Explanation

Choice A rationale

While blood pressure can increase during the second trimester due to changes in the maternal cardiovascular system, it doesn't typically increase *early* in the second trimester. Physiologic changes usually lead to a slight decrease in blood pressure during the first and early second trimester before gradually returning to pre-pregnancy levels or potentially increasing later.

Choice B rationale

While multiparous women can develop gestational hypertension or preeclampsia, having had "several pregnancies" in the past does not inherently increase the risk of high blood pressure at 14 weeks gestation in the current pregnancy, especially if previous pregnancies were normotensive. Risk factors like age, pre-existing conditions, and family history are more significant.

Choice C rationale

Advanced maternal age, generally considered 35 years or older, is a known risk factor for developing gestational hypertension and preeclampsia during pregnancy. Physiological changes associated with aging can affect vascular function and increase susceptibility to hypertensive disorders.

Choice D rationale

While addressing the client's feelings is important for therapeutic communication, it avoids answering her direct question about why her blood pressure is being taken. The nurse has a responsibility to provide accurate information regarding routine assessments during pregnancy.

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When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a 37-year-old G3P2 client who is at 14 weeks of gestation. The client asks, "why are you taking my blood pressure? It's always been normal.”. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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