SAUNDERS MATERNITY: Fetal Distress/Demise
The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1."We want to attend a support group." 2."We never want to try to have a baby again." 3."We are going to try to adopt a child immediately." 4."We are okay, and we are going to try to have another baby immediately."
1."We want to attend a support group." Rationale:A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that indicates positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process. Test-Taking Strategy(ies):Read all options carefully before selecting an answer and focus on the subject, the normal grieving process. Note that options 2, 3, and 4 are comparable or alike in that they relate to childbearing.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1.Administer oxygen via face mask. 2.Place the mother in a supine position. 3.Increase the rate of the oxytocin intravenous infusion. 4.Document the findings and continue to monitor the fetal patterns.
1.Administer oxygen via face mask. Rationale:Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Use the ABCs—airway, breathing, and circulation—and knowledge related to the significance of a late deceleration to answer this question.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate? 1.Notify the primary health care provider (PHCP). 2.Continue monitoring the fetal heart rate. 3.Encourage the client to continue pushing with each contraction. 4.Instruct the client's coach to continue to encourage breathing techniques
1.Notify the primary health care provider (PHCP). Rationale:A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Focus on the data in the question. Knowledge that the normal fetal heart rate is 110 to 160 beats per minute will assist you to recognize that fetal bradycardia is present.
The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1.Stop the oxytocin infusion. 2.Check the client's blood pressure. 3.Check the client for bladder distention. 4.Place the client in a side-lying position.
1.Stop the oxytocin infusion. Rationale:Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The primary health care provider is notified. The nurse should monitor the client's blood pressure and intake and output; however, the nurse should first stop the infusion. Test-Taking Strategy(ies):Focus on the subject, a nonreassuring FHR pattern, and note the strategic word, first. Recalling the adverse effects of oxytocin and the significance of this type of FHR pattern will direct you to option 1, stop the oxytocin infusion.
The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate. Which is the initial nursing action? 1.Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 2.Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. 3.Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. 4.Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.
1.Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. Rationale:If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned onto her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is then applied to the mother. Test-Taking Strategy(ies):Note the strategic word, initial. Eliminate options 2 and 4 first because the mother would not be turned onto her back. From the remaining choices, recall that oxygen by face mask at 8 to 10 L/min would provide the most oxygen to both mother and fetus.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? 1. Hemoglobin of 11 g/dL (110 mmol/L) 2. Fetal heart rate of 180 beats per minute 3. Maternal pulse rate of 85 beats per minute 4. White blood cell count of 12,000/mm3 (12 × 109/L)
2. Fetal heart rate of 180 beats per minute Rationale:A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of, 11,000-15,000/mm3 (11-15 × 109/L) up to 18,000/mm3 (18 × 109/L) During the immediate postpartum period, the white blood cell count may be 25,000-30,000/mm3 (25-30 × 109/L) because of increased leukocytosis that occurs during delivery. Test-Taking Strategy(ies):Focus on the subject, normal assessment and laboratory findings and those that indicate the need to contact the PHCP. Knowledge regarding the normal and abnormal findings in a pregnant client and fetus will direct you to the correct option.
The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? 1. No accelerations of fetal heart rate (FHR) 2. Moderate variability present 3. Variable decelerations present 4. FHR of 170 to 180 beats/minute
2. Moderate variability present Rationale:Reassuring signs in the fetal heart tracing include an FHR of 110 to 160 beats/minute, accelerations of the FHR, no variable decelerations, and the presence of moderate variability. The moderate variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations indicate cord compression. Test-Taking Strategy(ies):Focus on the subject, positive fetal heart responses. Note the words goal has been achieved in the question. Focusing on these words and recalling the normal fetal heart response to the labor process will direct you to the correct option.
A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate? 1. Document the findings. 2. Notify the primary health care provider (PHCP). 3. Inform the client that everything is normal and fine. 4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.
2. Notify the primary health care provider (PHCP). Rationale:The fetal heart rate should be 110 to 160 beats/minute during pregnancy. A fetal heart rate of 90 beats/minute (bradycardia) requires that the PHCP be notified and the client be evaluated further. The other options are inappropriate and delay necessary intervention. Test-Taking Strategy(ies):Knowledge of the normal fetal heart rate is required to answer this question. Options 1 and 3 are comparable or alike in that no action is taken with this finding and therefore can be eliminated first. Specific knowledge that the limits for the fetal heart rate are between 110 and 160 beats/minute will assist you in answering correctly.
The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? 1. Maternal fatigue 2. The passage of meconium 3. Coordinated uterine contractions 4. Progressive changes in the cervix
2. The passage of meconium Rationale:Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate; fetal acidosis; and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor. Test-Taking Strategy(ies):Focus on the subject, signs of fetal or maternal compromise in a client with dysfunctional labor. Maternal fatigue, coordinated uterine contractions, and progressive changes in the cervix are comparable or alike in that they are normal expectations during labor.
The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? 1.Increased urinary output 2.A fetal heart rate of 90 beats/minute 3.3 contractions occurring within a 10-minute period 4.Adequate resting tone of the uterus palpated between contractions
2.A fetal heart rate of 90 beats/minute Rationale:A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Test-Taking Strategy(ies):Focus on the subject, infusion needs to be discontinued. Eliminate increased urinary output first because it is unrelated to the use of oxytocin. Next, eliminate option 4 because of the words adequate resting tone. From the remaining choices, knowing that the normal fetal heart rate is 110 to 160 beats/minute will direct you to the correct option.
After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1.Reposition the laboring woman to knee-chest. 2.Assess the vagina and cervix with a gloved hand. 3.Notify the primary health care provider of the need for an amnioinfusion. 4.Document the description of the fetal bradycardia in the nursing notes.
2.Assess the vagina and cervix with a gloved hand. Rationale:It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated. Test-Taking Strategy(ies):Note the strategic word, priority, which indicates the first step the nurse must take to confirm and possibly remedy this serious condition. Although all of these options may be correct interventions for cord compression in utero or cord prolapse, the initial action of the nurse should be focused on finding the reason for the fetal bradycardia and remedying the problem.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1.Notify the primary health care provider. 2.Discontinue the infusion of oxytocin. 3.Place oxygen on at 8 to 10 L/minute via face mask. 4.Contact the client's primary support person(s) if not currently present.
2.Discontinue the infusion of oxytocin. Rationale:The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time. Test-Taking Strategy(ies):Focus on the strategic word, priority. Focus on the data in the question and note the relationship of the words undergoing induction and the correct option. Also recall that physiological needs are prioritized over psychosocial needs.
On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations? 1.Episodic, late decelerations that indicate uteroplacental insufficiency 2.Periodic, early decelerations that indicate fetal head compression 3.Periodic, variable decelerations that indicate cord compression 4.Episodic, early decelerations that may be a result of maternal hypotension
2.Periodic, early decelerations that indicate fetal head compression Rationale:An early deceleration is described as a visually apparent gradual decrease of the FHR with a gradual return to the FHR baseline. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described; therefore, eliminate option 3. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4. Test-Taking Strategy(ies):Focus on the subject, the characteristics of the decelerations. Knowledge of the different changes in the FHR is required to answer this question. Remember that an early deceleration is described as a visually apparent gradual decrease of the FHR with a gradual return to the FHR baseline.
The nurse is preparing to care for a client in labor. The primary health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside
3. Continuous electronic fetal monitoring Rationale:Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary. Test-Taking Strategy(ies):Use the ABCs-airway, breathing, and circulation-to assist you in answering the question. The correct option is the only one that addresses oxygenation and circulation.
The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? 1. Prepare the client for a cesarean delivery. 2. Monitor the FHR every 30 minutes. 3. Encourage an upright or side-lying maternal position. 4. Increase the rate of the oxytocin infusion every 10 minutes.
3. Encourage an upright or side-lying maternal position.
The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply. 1. Quickening 2. Braxton Hicks contractions 3. Fetal heart rate of 180 beats/minute 4. Consistent increase in fundal height 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP)
3. Fetal heart rate of 180 beats/minute 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP) Rationale:The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/minute in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 110 to 160 beats/minute. An elevated MSAFP should be followed up with more specialized testing to determine if a neural tube problem exists. The remaining options are normal expected findings. Test-Taking Strategy(ies):Note the strategic words, need for follow-up, and note that the client is in the second trimester of pregnancy. The words need for follow-up indicate a negative event query and ask you to select the options that are a concern. Recalling the normal fetal heart rate and noting the word elevated in option 5 will direct you to the correct option.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the obstetrician (OB). 4. Tell the client that the fetal heart rate is normal.
3. Notify the obstetrician (OB). Rationale:The FHR depends on gestational age and ranges from 160 to 170 beats per minute in the first trimester but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the OB. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the OB needs to be notified. Test-Taking Strategy(ies):Focus on the data in the question and note the strategic word, priority. Then, note if an abnormality exists. Also note the FHR and that the client is at 38 weeks of gestation. Remember that the normal FHR is 110 to 160 beats per minute.
The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate
3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate Rationale:Oxytocin stimulates uterine contractions and is a pharmacological method to induce labor. Late decelerations, a nonreassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation, late decelerations, or other adverse effects occur. Some obstetricians prescribe the administration of oxytocin in 10-minute pulsed infusions rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress. Test-Taking Strategy(ies):Note the strategic word, immediately. Focus on the subject, an adverse effect of oxytocin. Options 1 and 2 are comparable or alike and can be eliminated first. From the remaining options, recalling that early decelerations of the fetal heart rate are a reassuring sign will direct you to the correct options.
Which assessment finding after an amniotomy should be conducted first? 1.Cervical dilation 2.Bladder distention 3.Fetal heart rate pattern 4.Maternal blood pressure
3.Fetal heart rate pattern Rationale:Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy. Test-Taking Strategy(ies):Note the strategic word, first. Because of the risk of a prolapsed cord after an amniotomy, the first action is to check the fetal heart rate for signs of nonreassuring fetal heart rate patterns.
The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. 1.Early labor 2.Amniotomy 3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies
3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies Rationale:The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into 4 different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition. Test-Taking Strategy(ies):Note the strategic words, most likely, and focus on the subject, minimal variability. Early labor typically does not result in fetal hypoxia. An amniotomy may result in cord compression or a prolapsed cord leading to variable decelerations but does not lead to variability issues that relate to baseline fetal heart rate.
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the intravenous flow rate. 2. Continue the oxytocin drip if infusing. 3. Place the client in a high Fowler's position. 4. Administer oxygen, 8 to 10 L/minute, via face mask.
4. Administer oxygen, 8 to 10 L/minute, via face mask. Rationale:Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect, because the intravenous infusion should be increased (per primary health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect, because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Test-Taking Strategy(ies):Note the strategic words, most important. Use the ABCs—airway, breathing, and circulation. Oxygen is the only option that would improve cardiac output and improve perfusion to the fetus. The other options would not improve perfusion to the fetus.
A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? 1. Lack of power about the situation 2. Grieving because of the loss of the baby 3. Lack of knowledge regarding what occurred 4. Concern about the loss of the baby and personal health
4. Concern about the loss of the baby and personal health Rationale:The client expresses that there is no way out of the situation except for death; therefore, the client exhibits concern about the loss of the baby and personal health. The data given do not support lack of power. Grieving is a possible client problem at a later time; however, at this time the concern over the loss should take priority. Lack of knowledge is a possible problem later, but not enough data support it at this point, and it is not the priority. Test-Taking Strategy(ies):Note the strategic word, priority. Focus on the data in the question, the complication of DIC and the comment made by the client, and note the relationship of those data to the correct option.
A 39-week-gestation pregnant client calls the maternity unit, stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which is the best response made by the nurse? 1. "Six to eight fetal movements in a 24-hour period are adequate to determine that the fetus is healthy." 2. "Fetal movement is a sign of fetal health. Even if the amount has decreased, the fetus is still healthy." 3. "Continue to count fetal movements for the next 24 hours and call your primary health care provider if the number of movements continues to decrease." 4. "Fetal movements do not decrease as a woman nears term; therefore, you should be seen by your primary health care provider for further evaluation."
4. "Fetal movements do not decrease as a woman nears term; therefore, you should be seen by your primary health care provider for further evaluation." Rationale:Fetal movements may decrease during fetal sleep cycles and while a woman is taking depressant medication, drinking alcohol, or smoking cigarettes. A decrease in fetal movement over a period of 1 or more days or as a woman approaches term is abnormal and requires further evaluation for fetal well-being. In most protocols for fetal movement, 10 movements in any designated amount of time (usually 2 or 3 hours) is the minimal number required to determine fetal health, so option 1 can be eliminated because it does not meet the minimal fetal movement requirement. Although fetal movement is a reassuring sign of fetal health, fetal movement that is perceived as being less than on the previous day could indicate a decrease in fetal oxygenation and a need for further evaluation, so therefore eliminate option 2. Option 3 can be eliminated because this recommendation would delay time that could be used to diagnose a possible at-risk fetus. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject, daily fetal movement count. Recall the guidelines for determining a healthy fetus versus the need for further evaluation of the fetus. Noting the words baby has not moved very much in the past few days will direct you to the correct option.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Tell the client that the fetal heart rate is normal. 4. Notify the primary health care provider (PHCP).
4. Notify the primary health care provider (PHCP). Rationale:The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the PHCP. Options 2 and 3 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the PHCP needs to be notified. Test-Taking Strategy(ies):Note the strategic word, priority. Then, note if an abnormality exists. Also note the FHR and that the client is at 38 weeks of gestation. Remember that the normal FHR at or near term is 110 to 160 beats/minute.
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1.Maternal fatigue 2.Coordinated uterine contractions 3.Progressive changes in the cervix 4.Persistent nonreassuring fetal heart rate
4.Persistent nonreassuring fetal heart rate Rationale:Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor. Test-Taking Strategy(ies):Focus on the subject, signs of fetal or maternal compromise. Eliminate options 1, 2, and 3 because they are comparable or alike and are normal expectations during labor.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1.Variability 2.Accelerations 3.Early decelerations 4.Variable decelerations
4.Variable decelerations Rationale:Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction. Test-Taking Strategy(ies):Focus on the subject, umbilical cord compression. Recalling that variable decelerations occur if the umbilical cord becomes compressed will direct you to the correct option.
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."
1. "What can I do for you?" Rationale:When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their primary health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious/spiritual practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings. Test-Taking Strategy(ies):Use knowledge of therapeutic communication techniques to answer the question. The correct option is the only option that reflects use of therapeutic communication techniques.