Which of the following is a characteristic of a reassuring fetal heart rate pattern?
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Solution
Answer D is correct. Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
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Solution
Answer C is correct. The initial action by the nurse observing a variable deceleration should be to turn the client to the side, preferably the left side. Administering oxygen is also indicated. Answer A is incorrect because the question asks for the initial action. The initial action should be to turn the client to her side. If this does not resolve the problem, call the doctor. Answers B and D are incorrect because there is no data to indicate that the monitor is applied incorrectly.
As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
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Solution
Answer D is correct. This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer A is incorrect because decelerations are not caused by fetal sleep, answer B results in a variable deceleration, and answer C is indicative of an early deceleration.
Which nursing diagnoses is most appropriate for the client as she completes the latent phase of labor?
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Solution
Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid is not sufficient to prevent dehydration. Answer A is incorrect because impaired gas exchange related to hyperventilation is not a risk to the client. Answer B is incorrect because alteration in oxygen perfusion related to maternal position is not a problem encountered by the client at the end of the early phase of labor. Answer C is incorrect because not all clients have fetal monitoring.
The nurse is caring for a gravida 1 admitted in labor. Which finding would suggest the need for an internal fetal monitor?
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Solution
Answer B is correct. Answer B is correct. There are only a few reasons to apply an internal monitor: if the fetus is in distress or if the fetal heart tones cannot be assessed using the external monitor. Answer A is incorrect because cervical dilation is not a reason to apply an internal monitor. Answer C is incorrect because the fact that the fetus is at 0 station is not a reason to apply an internal monitor. Answer D is also incorrect because noting contractions every 3 minutes is not a reason to apply an internal monitor. It is not necessary for a scalp electrode placement, as long as the membranes are still intact.
A vaginal exam reveals a breech presentation. The nurse should take which of the following actions at this time?
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Solution
Answer B is correct. A breach presentation calls for applying a fetal heart monitor. Answer A is incorrect because there is no need to prepare for a Caesarean section at this time. Answer C is incorrect because placing the client in Trendelenburg position is also not an indicated action. Answer D is incorrect because there is no need for an ultrasound based on the finding.
The nurse is monitoring the client admitted for induction of labor.The nurse knows that Pitocin has been effective when:
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Solution
Answer D is correct. The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, so answer A is incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is incorrect because the word infrequent indicates irregular contractions.
The client is having fetal heart rates of 100–110bpm during the contractions. The first action the nurse should take is:
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Solution
Answer B is correct. The normal fetal heart rate is 120–160bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time, so answer D is incorrect.
The client is admitted to the unit. Vaginal exam reveals that she is 3cm dilated. Which of the following statements would the nurse expect her to make?
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Solution
Answer D is correct. Dilation of 3cm is the end of the latent phase of labor, so a request for an epidural would be expected. Answer A is a vague answer, and answer B would indicate the end of the first stage of labor, or complete dilation. Answer C indicates the transition phase and, thus, is incorrect.
A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make after the amniotomy?
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Solution
Answer B is correct. Normal amniotic fluid is straw colored and odorless. An amniotomy is an artificial rupture of membranes. Fetal heart tones of 160 indicate tachycardia, so answer A is incorrect. Greenish fluid is indicative of meconium, so answer C is incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord. This would need to be reported immediately; therefore, answer D is incorrect.