The labor and delivery nurse is caring for a client in active labor.
The nurse notes the fetal heart rate baseline is 175 bpm, moderate variability.
Accelerations are absent and no decelerations noted.
How should the nurse describe this tracing to the medical provider?
Category I.
Category II.
Category III.
Category IV.
The Correct Answer is B
Choice A rationale
Category I tracings are considered normal and are associated with a well-oxygenated, non-acidotic fetus with a normal fetal heart rate baseline, moderate variability, and no late or variable decelerations. However, a baseline heart rate of 175 bpm is considered tachycardia, which does not fit the criteria for Category I.
Choice B rationale
Category II tracings are indeterminate and include any fetal heart rate pattern that does not fit into Category I or III. A baseline heart rate of 175 bpm with moderate variability and no accelerations or decelerations fits into this category. This indicates that the fetus may be experiencing some stress but is not in immediate danger.
Choice C rationale
Category III tracings are abnormal and are associated with an increased risk of fetal acidemia. These tracings include absent baseline variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern. The given tracing does not meet these criteria as it shows moderate variability and no decelerations.
Choice D rationale
There is no Category IV in the classification of fetal heart rate tracings. The standard classification includes only Categories I, II, and III.
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View Related questions
Correct Answer is B
Explanation
Choice A rationale
Early decelerations are characterized by a gradual decrease and return to baseline of the fetal heart rate that coincides with the peak of a contraction. They are typically benign and related to fetal head compression.
Choice B rationale
Late decelerations are characterized by a gradual decrease and return to baseline of the fetal heart rate that occurs after the peak of a contraction. They are associated with uteroplacental insufficiency and require prompt intervention to improve fetal oxygenation.
Choice C rationale
Variable decelerations are characterized by an abrupt decrease in fetal heart rate that varies in duration, intensity, and timing relative to contractions. They are often caused by umbilical cord compression and may require interventions to relieve the compression.
Choice D rationale
Prolonged decelerations are characterized by a decrease in fetal heart rate that lasts longer than 2 minutes but less than 10 minutes. They indicate a more severe and sustained disruption in fetal oxygenation and require immediate intervention.
Correct Answer is C
Explanation
Choice A rationale
Keeping four side rails up is a safety measure to prevent falls, but it is not specific to the care of a client in active labor. It is a general safety precaution used for clients who are at risk of falling or have impaired mobility.
Choice B rationale
Inserting an indwelling urinary catheter is not a routine action for a client in active labor. Catheterization is typically reserved for specific medical indications, such as urinary retention or the need for accurate urine output measurement in certain high-risk situations.
Choice C rationale
Checking the cervix prior to administering medication is crucial in active labor. This ensures that the medication is appropriate for the stage of labor and helps avoid complications such as administering pain relief too early or too late, which could affect labor progression and fetal well-being.
Choice D rationale
Monitoring the fetal heart rate (FHR) every hour is important, but it may not be frequent enough in active labor. Continuous or more frequent monitoring is often required to promptly detect any signs of fetal distress and take appropriate actions.