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 E
Explanation
a. Inevitable abortion is characterized by vaginal bleeding, cramping, and dilated cervical os.
b. Septic abortion is associated with infection and may present with fever, chills, and foul-smelling vaginal discharge.
c. Incomplete abortion involves vaginal bleeding, cramping, and dilation of the cervical os with passage of some products of conception.
d. A missed abortion is when there is no bleeding or cramping, but the pregnancy has stopped developing and there is no fetal heartbeat. The cervix may be closed or slightly open, and the uterus may be smaller than expected for gestational age.
e. Threatened abortion involves vaginal bleeding with a closed cervical os and no passage of products of conception. It signifies a potential abortion, but the pregnancy may continue.
Correct Answer is A
Explanation
a. Anasarca, which refers to generalized edema or swelling, can be a sign of a serious medical condition such as preeclampsia or heart failure and should prompt immediate medical evaluation.
b. Morning vomiting is a common discomfort in the first trimester of pregnancy and typically does not require immediate medical attention unless it is severe or persistent.
c. Braxton Hicks contractions, which are mild and irregular contractions that can occur throughout pregnancy, are typically not a cause for concern.
d. Frequent urination is a common discomfort in the first trimester of pregnancy and typically does not require immediate medical attention unless it is accompanied by other symptoms.
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