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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Correct Answer is B
Explanation
Choice A rationale
Uterine contractions that cause variable decelerations are not specific to true labor. Variable decelerations are typically associated with umbilical cord compression and can occur during both true and false labor.
Choice B rationale
Regular uterine contractions that cause cervical change are a definitive sign of true labor. True labor is characterized by contractions that become progressively stronger, more frequent, and more regular, leading to cervical dilation and effacement. This process indicates that the body is preparing for childbirth.
Choice C rationale
The station of the presenting part refers to the position of the fetus in relation to the ischial spines of the pelvis. While it is an important aspect of labor progression, it is not a definitive sign of true labor.
Choice D rationale
Rupture of the membranes, or the breaking of the water, can occur before true labor begins. While it often indicates that labor is imminent, it is not a definitive sign of true labor on its own.
Correct Answer is A
Explanation
Choice A rationale
- Thenon-stress test (NST)is reactive, indicating normal fetal heart rate patterns with adequate accelerations.
- Theultrasoundshows normal amniotic fluid index and fetal movements, with no abnormalities detected.
- The client has no significant medical history and is generally feeling well.
These findings suggest that the fetus is currently well, and there is no immediate need for further intervention. However, the client should be instructed to monitor fetal movements at home and return if there are any concerns or if decreased fetal movement persists. This approach balances the need for vigilance with the reassurance provided by the normal test results.
.
Choice B rationale
Continuous fetal monitoring is typically reserved for cases where there is a significant concern for fetal distress or other complications. In this case, both the non-stress test (NST) and ultrasound results are normal, indicating that the fetus is currently well. Therefore, continuous monitoring in a hospital setting is not necessary.
Choice C rationale
An immediate cesarean section is a major surgical procedure that is usually performed when there is an urgent risk to the mother or baby. Given the normal NST and ultrasound findings, there is no indication of fetal distress or other complications that would warrant such an intervention at this time.
Choice D rationale
Corticosteroids are given to enhance fetal lung maturity in cases where preterm delivery is anticipated, typically before 34 weeks of gestation. Since the client is already at 35 weeks and there is no indication of imminent preterm labor or other complications, administering corticosteroids is not necessary..