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Early decelerations are not indicative of increased fetal intracranial pressure. They are characterized by a gradual decrease in fetal heart rate (FHR) that mirrors the contraction, with the nadir of the deceleration occurring at the peak of the contraction. This pattern is considered benign and is caused by fetal head compression during a uterine contraction, which stimulates the vagus nerve and results in a transient, brief decrease in FHR.

The term "present decelerations" is not a recognized classification for fetal heart rate patterns. Fetal heart rate (FHR) decelerations are categorized as early, late, or variable, each corresponding to a different underlying physiological cause. Passage through the cervix is a mechanical process; while it causes head compression, the resulting FHR change is the early deceleration pattern.

The term "absent deceleration" is not a specific fetal heart rate pattern. A baseline fetal heart rate that remains within the normal range of 110 to 160 beats per minute (bpm) with no periodic changes (decelerations or accelerations) is a normal finding. Fetal movement is primarily assessed by accelerations in the FHR, which are increases of at least 15 bpm lasting 15 seconds or more.

Oxytocin is an uterotonic agent used to induce or augment labor or to prevent/control postpartum hemorrhage; it has no role in correcting hypotension caused by a neuraxial block, such as an epidural. The hypotension is due to sympathetic blockade causing peripheral vasodilation and subsequent venous pooling, decreasing venous return and cardiac output.

While oxygen administration may be part of the treatment for fetal distress secondary to maternal hypotension, administering it at 6 liters via face mask is not the priority action. The immediate priority is to restore maternal blood pressure to ensure adequate placental perfusion and oxygen delivery to the fetus by increasing preload.

Raising the head of the bed would worsen the hypotension because it promotes gravitational pooling of blood in the lower extremities, further decreasing venous return to the heart and exacerbating the drop in cardiac output. The preferred position is lateral (side-lying) or a slight Trendelenburg (feet higher than head) to promote blood return

Fetal heart rate variability (fluctuations in the FHR baseline) is an indicator of a healthy fetal nervous system and oxygenation and is a focus of the first and second stages of labor. After the baby is born (end of the third stage), fetal monitoring is no longer relevant; the maternal state and uterine involution are the priorities.

While comfort is important throughout labor and post-delivery, the desired physiological outcome at the end of the third stage is focused on preventing hemorrhage. Some discomfort is expected due to uterine contractions ("afterpains") and is an indicator of the desired uterine contraction necessary for hemostasis.

A maternal respiratory rate within the expected range (12 to 20 breaths per minute) is a general goal throughout labor. However, the most critical and unique outcome specific to the end of the third stage is the firm uterine contraction to achieve hemostasis and prevent the life-threatening complication of postpartum hemorrhage.

Assessing the characteristics of the amniotic fluid (color, odor, amount, consistency) is an important step after amniotomy, as meconium-stained fluid indicates fetal stress. However, checking the fetal heart rate (FHR) is the priority because a sudden change or drop in FHR may indicate a prolapsed umbilical cord, a life-threatening emergency, making immediate FHR assessment the most critical intervention.

Monitoring for infection is a necessary long-term post-amniotomy intervention because the rupture of the amniotic membranes breaks the protective barrier to the uterus. The nurse should check the client's temperature every 2 hours after the procedure. However, the immediate risk is fetal compromise from a cord prolapse, which must be ruled out first.

Inspecting the perineum for bloody discharge is part of the overall assessment, as labor progression and cervical changes can cause some bloody show. However, new heavy bright red bleeding could indicate a placental abruption, which is a concern. The most critical and immediate danger following amniotomy is umbilical cord prolapse, making FHR assessment the priority.

Incorrect. The FHR tracing clearly demonstrates fluctuations consistent with moderate variability, which reflects healthy fetal autonomic nervous system function and adequate oxygenation. The baseline is within the normal range (110–160 bpm), appearing at 130–140 bpm. No periodic changes are present—specifically, there are no accelerations (≥15 bpm above baseline for ≥15 seconds) or decelerations.

Incorrect. This option misidentifies the variability. The tracing shows moderate variability, not minimal (≤5 bpm). Minimal variability may be associated with fetal sleep cycles, prematurity, or hypoxia. Here, the strip demonstrates clear, irregular fluctuations >5 bpm. The baseline is normal, and the absence of accelerations and decelerations is correctly noted..

Incorrect. While moderate variability (6–25 bpm) is present, the tracing shows no accelerations or decelerations. This makes the documentation inaccurate. Early decelerations, which align with contractions and indicate fetal head compression, are not observed on this strip.

Hegar's sign is a probable sign of pregnancy. It is the softening of the lower uterine segment or isthmus, typically occurring about 6-12 weeks gestation due to increased vascularity and fluid accumulation. Probable signs are objective, detectable by a provider, but can be caused by conditions other than pregnancy, making them less definitive than positive signs.

Chadwick sign is a probable sign of pregnancy. It is the deep, dusky-blue coloration of the vaginal and cervical mucosa due to increased blood flow (hyperemia) and vascularity, often observable from 6-8 weeks gestation. Probable signs are objective changes noted by a provider but are not absolutely specific to pregnancy, as other conditions could cause pelvic vascular congestion.

A Positive pregnancy test (urine or serum) is considered a probable sign of pregnancy. These tests detect the presence of Human Chorionic Gonadotropin (hCG). While highly reliable, conditions like hydatidiform mole or certain medications can cause a false positive result, preventing it from being a definitive positive sign, which only includes visualization of the fetus, fetal heart tones, or palpation of fetal movement by an examiner.

Epidural anesthesia is a highly effective pharmacologic pain management option for labor, but it is typically offered later in the active phase of labor or upon request. At 3 cm dilation, the client is in the early (latent) phase of the first stage of labor. While the client can receive it, the initial nursing priority is often to promote comfort and coping with non-pharmacologic measures before resorting to invasive procedures.

Narcotic analgesia (opioids) can be used for pain relief in early labor, but they can cause fetal/neonatal respiratory depression, maternal drowsiness, and potential nausea. Given the client is at 3 cm, this is the latent phase, and non-pharmacologic methods are typically encouraged first. Pharmacologic agents are often reserved for when non-pharmacologic methods are insufficient or the client enters the active phase (6 cm or more).

A client in active labor, particularly one receiving analgesia, is at risk of aspiration should an emergency Cesarean section be required under general anesthesia. Therefore, generally, clients are kept NPO (nothing by mouth) except for small amounts of clear liquids or ice chips. Offering a full breakfast is contraindicated due to the risk of aspiration and is not a priority for comfort or labor management.

Maternal uterine contractions are utilized during a Contraction Stress Test (CST) to assess fetal response to the stress of decreased placental perfusion. However, a Nonstress Test (NST) is a non-invasive procedure monitoring FHR response to fetal movement without inducing contractions. The NST is deemed reactive/non-reactive based on the FHR acceleration patterns, which are largely indicative of fetal physical activity and reserve.

Fetal gestational age is a key determinant for the criteria of a reactive NST. Before 32 weeks, an acceleration is defined as an increase of ≥ 10 bpm lasting ≥ 10 seconds. After 32 weeks, the criteria are ≥ 15 bpm lasting ≥ 15 seconds, as seen in this scenario. However, the reason for the reactive result itself is the healthy response of the FHR to fetal physical activity, indicating a healthy central nervous system.

Maternal blood pressure is monitored during the NST as part of the overall assessment, but it is not the reason for a reactive interpretation. Fetal bradycardia or decelerations may be linked to maternal hypotension (e.g., from supine positioning), but the core finding for reactivity is the transient FHR accelerations, which reflect a healthy autonomic nervous system responding to fetal physical activity.

Indeterminate is a term primarily used to classify Fetal Heart Rate (FHR) tracings that fall into Category II, meaning they do not meet the criteria for Category I (normal) or Category III (abnormal). This term is not used to document uterine contraction frequency or intensity. Uterine activity is typically quantified by the number of contractions in a 10-minute window, averaged over 30 minutes, or by intensity..

Normal uterine activity is defined as five or fewer contractions in 10 minutes, averaged over a 30-minute window. By observing the lower tracing (uterine activity/UA), there are 3 to 4 contractions within a typical 10-minute segment. This falls within the expected range for a laboring client. The contractions are spaced appropriately, allowing for adequate uterine resting tone and placental perfusion..

Bradycardia is a term used to describe a slow Fetal Heart Rate (FHR), specifically a baseline FHR less than 110 beats per minute (bpm). This is a measure of the fetus's heart rate, not a descriptor for uterine contraction frequency or pattern. The uterine activity is described by frequency, duration, and intensity, not heart rhythm terms like bradycardia.