A nurse is walking by a client's room and can hear the fetal heart rate dropping.
The nurse observes the heartbeat and interprets the monitor strip as indicating which of the following?
Uteroplacental insufficiency.
Umbilical cord compression.
Maternal bradycardia.
Fetal head compression.
The Correct Answer is B
Choice A rationale
Uteroplacental insufficiency typically results in late decelerations, not a sudden drop in fetal heart rate, which is more commonly caused by umbilical cord compression.
Choice B rationale
Umbilical cord compression can cause variable decelerations, which are characterized by a sudden drop in fetal heart rate. This occurs due to the umbilical cord being compressed,
leading to decreased blood flow and oxygen to the fetus.
Choice C rationale
Maternal bradycardia refers to a slow maternal heart rate and does not directly cause changes in the fetal heart rate pattern.
Choice D rationale
Fetal head compression typically causes early decelerations, which are gradual decreases in fetal heart rate that occur with contractions and are usually benign.
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Correct Answer is B
Explanation
Choice A rationale
Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.
Choice B rationale
Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.
Choice C rationale
Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.
Choice D rationale
Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.
Correct Answer is ["A","B","C"]
Explanation
Choice A: Give betamethasone 12 mg IM now and repeat in 24 hr.
Rationale: Betamethasone is administered to accelerate fetal lung maturity in cases of preterm labor. Given the client's gestational age of 31 weeks, this intervention is appropriate to help reduce the risk of respiratory distress syndrome in the newborn.
Choice B: Begin loading dose of magnesium sulfate 9 g over 30 min.
Rationale: Magnesium sulfate is used for neuroprotection of the fetus in preterm labor to reduce the risk of cerebral palsy. The loading dose is typically given to achieve therapeutic levels quickly.
Choice C: Position the client in a lateral position.
Rationale: Positioning the client in a lateral position helps improve uteroplacental blood flow and can reduce the intensity of contractions, which is beneficial in managing preterm labor.