While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate during the contraction's peak, with the nadir of the decelerations occurring when the contraction end. The nurse's first priority is to:
Select one:
Insert a scalp electrode.
Notify the care provider.
Assist with amnioinfusion.
Reposition the patient.
The Correct Answer is D
a. A scalp electrode is not indicated unless there is a problem with the external monitor tracing or if further assessment of the fetal heart rate variability is needed.
b. This is important but repositioning the patient is the priority.
c. Amnioinfusion is only done if repositioning the patient does not resolve the late decelerations.
d. The nurse is observing late decelerations of the fetal heart rate, which indicate uteroplacental insufficiency and fetal hypoxia. The nurse's first priority is to reposition the patient to improve placental blood flow and oxygen delivery to the fetus. Repositioning can be done by turning the patient to her side, elevating her legs, or placing a wedge under her hip.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. This is a common cause of variable decelerations, not early decelerations.
b. This is not a cause of early decelerations.
c. This is a common cause of variable decelerations, not early decelerations.
d. This is the cause of early decelerations and is a normal response to the pressure of the fetal head on the cervix during contractions.
Correct Answer is A
Explanation
a. Endometriosis is a condition in which the tissue that normally lines the inside of the uterus grows outside the uterus, causing severe pain and other symptoms.
b. Primary dysmenorrhea is the term used to describe painful menstrual cramps that are not caused by another condition.
c. Premenstrual syndrome (PMS) is a collection of physical and emotional symptoms that occur in the days or weeks before a woman's period.
d. Secondary dysmenorrhea is the term used to describe painful menstrual cramps that are caused by another condition, such as endometriosis.
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