While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
Maternal pulse rate of 100 bpm.
Maternal blood pressure of 120/70 mm Hg.
Decrease in intensity of uterine contractions.
Persistent fetal bradycardia below 100 bpm.
The Correct Answer is D
The correct answer is: d. Persistent fetal bradycardia below 100 bpm.
Choice A: Maternal pulse rate of 100 bpm
A maternal pulse rate of 100 beats per minute (bpm) is slightly elevated but not uncommon during labor due to the physical exertion and stress involved. The normal range for an adult’s resting heart rate is typically between 60 and 100 bpm. While it is important to monitor the maternal pulse, it is not an immediate cause for concern unless accompanied by other symptoms such as hypotension, chest pain, or signs of distress.
Choice B: Maternal blood pressure of 120/70 mm Hg
A maternal blood pressure of 120/70 mm Hg is within the normal range. Normal blood pressure for adults is generally considered to be around 120/80 mm Hg. This reading indicates that the mother is maintaining stable blood pressure during labor, which is a positive sign. Therefore, this does not require immediate reporting to the physician.
Choice C: Decrease in intensity of uterine contractions
A decrease in the intensity of uterine contractions can be concerning as it may indicate ineffective labor, which could prolong the delivery process. However, this is typically managed by adjusting oxytocin levels or other interventions and does not require immediate reporting unless it leads to other complications such as fetal distress.
Choice D: Persistent fetal bradycardia below 100 bpm
Persistent fetal bradycardia below 100 bpm is a significant concern and should be immediately reported to the physician. Normal fetal heart rate ranges from 110 to 160 bpm. Bradycardia, defined as a heart rate below 110 bpm, can indicate fetal distress, hypoxia, or other complications that may require urgent intervention to ensure the safety of the fetus. Persistent bradycardia, especially below 100 bpm, necessitates immediate medical attention to assess and address the underlying cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
This is incorrect because WIC does not provide immunizations for high-risk infants and children. Immunizations are provided by other health care services, which WIC may refer participants to.
Choice B reason:
This is incorrect because WIC does not screen for infants with developmental disorders. WIC provides nutrition education and referrals to other health and social services but does not diagnose or treat any medical conditions.
Choice C reason:
This is correct because WIC provides supplemental food supplies to low-income pregnant or breastfeeding women, as well as infants and children up to age 5 who are at nutritional risk. The food packages are designed to meet the special nutritional needs of the participants and include items such as fruits, vegetables, milk, cheese, cereal, bread, juice, peanut butter, eggs, and infant formula.
Choice D reason:
This is incorrect because WIC does not provide well-child examinations for infants and children living at the poverty level. WIC may refer participants to other health care services that provide such examinations but do not conduct them themselves.
Correct Answer is A
Explanation
Choice A reason:
Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.
Choice B reason:
Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.
Choice C reason:
Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.
Choice D reason:
Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.
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