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?
Category 1.
Category 2.
Category 3.
Category 4. .
Category 4. .
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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Correct Answer is A
Explanation
Choice A rationale
Uterine atony is a common complication following polyhydramnios because the excessive amniotic fluid can lead to uterine overdistension, which in turn can cause poor uterine
muscle tone and increased risk of postpartum hemorrhage.
Choice B rationale
Thrombophlebitis is an inflammation of a vein with clot formation, but it is not directly associated with polyhydramnios.
Choice C rationale
Postpartum preeclampsia is high blood pressure and signs of organ damage after delivery, but there is no direct link between polyhydramnios and this condition.
Choice D rationale
Retained placental fragments can lead to postpartum hemorrhage but are not specifically associated with polyhydramnios.
Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 10/min is concerning as it indicates possible respiratory depression, which can be a side effect of spinal anesthesia. This requires immediate intervention to
prevent hypoxia and other complications.
Choice B rationale
Blood pressure of 100/70 mm Hg is within normal limits and does not require immediate intervention in this context.
Choice C rationale
Urinary output of 30 ml/hr is slightly low, but it is not immediately life-threatening. It may require monitoring and further assessment if it persists.
Choice D rationale
A headache pain rated a 6 on a scale of 0 to 10 could indicate a post-dural puncture headache, which is common after spinal anesthesia. It requires attention but is not an immediate
life-threatening condition. .