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 A

Explanation

Choice A rationale

G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).

Choice B rationale

This option incorrectly states L as 2. The client has one living child from the previous pregnancy.

Choice C rationale

This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.

Choice D rationale

This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.

A. Reactive Non-stress test. B. Non-reactive Non-stress test. C. Negative Non-stress test. D. Positive Non-stress test.

Correct Answer is A

Explanation

Choice A rationale

A reactive non-stress test indicates fetal well-being. The criteria for a reactive NST in a fetus greater than 32 weeks gestation include two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline lasting for at least 15 seconds within a 20-minute period. The baseline fetal heart rate should be within the normal range of 110 to 160 beats per minute. This client's results meet these criteria.

Choice B rationale

A non-reactive non-stress test lacks the required number of fetal heart rate accelerations or the accelerations do not meet the amplitude or duration criteria within the specified time frame. This suggests the fetus may be experiencing some form of stress and requires further evaluation.

Choice C rationale

A negative non-stress test is not a standard term used to describe NST results. The test is categorized as either reactive (indicating fetal well-being) or non-reactive (suggesting potential fetal compromise).

Choice D rationale

A positive non-stress test is also not a standard term used for NST interpretation. A positive result in fetal monitoring typically refers to a contraction stress test where late decelerations are observed, indicating potential uteroplacental insufficiency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

When performing a Non-Stress test, the nurse interprets the finding of two accelerations of the fetal heart rate of 15 beats per minute above the baseline rate of 135 beats per minute lasting for 15 seconds in 20 minutes.This should be documented as:

Correct Answer is A

Explanation

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