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A client arrives at OB triage with complaints of decreased fetal movement for the past 24 hours.
The client states, "I see the high-risk clinic because I have chronic hypertension and gestational diabetes.”. The nurse applies the external fetal monitors and identifies a fetal heart rate baseline of 120 bpm, absent variability, no accelerations, and recurrent late decelerations.

What fetal heart rate category would the nurse communicate to the provider?

A.

Category 1.

B.

Category 2.

C.

Category 3.

D.

Category 4. .

E.

Category 4. .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Category 1 is a normal fetal heart rate pattern with no signs of fetal distress, which is not applicable in this case.

 

Choice B rationale

Category 2 represents an intermediate category with some concerns, but recurrent late decelerations and absent variability place this scenario in a higher risk category.

 

Choice C rationale

Category 3 indicates abnormal fetal heart rate patterns, including absent variability with recurrent late decelerations, which is associated with potential fetal hypoxia or acidemia and requires prompt intervention.

 

Choice D rationale

There is no Category 4 in fetal heart rate monitoring.

 


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View Related questions

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale

Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to

monitor labor progression.

Choice B rationale

Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.

Choice C rationale

Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.

Choice D rationale

Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.

Choice E rationale

Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord

compression effects. .

Correct Answer is D

Explanation

Choice A rationale

Phototherapy is a treatment for jaundice but is not a preventive measure. It is used after jaundice has been identified to reduce bilirubin levels in the newborn.

Choice B rationale

Suctioning excess mucus with a bulb syringe helps clear the newborn’s airways but does not have a direct role in preventing jaundice. Jaundice is related to bilirubin metabolism, not

mucus accumulation.

Choice C rationale

Preparing for an exchange blood transfusion is an intervention for severe hyperbilirubinemia but is not a preventive measure for jaundice. It is used when bilirubin levels are

extremely high.

Choice D rationale

Initiating early feeding helps to promote bowel movements, which assists in the excretion of bilirubin from the body. This is an effective preventive measure for jaundice, as it helps

reduce the chances of bilirubin buildup.

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