The nurse is caring for a client in labor at term. The nurse reviews the external monitor tracing below. The nurse identifies that the deceleration pattern seen indicates which of the following?
Early decelerations.
Late decelerations.
Variable decelerations.
Prolonged decelerations.
The Correct Answer is B
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.
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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
Amniocentesis is a diagnostic test that involves extracting a small amount of amniotic fluid from the uterus to test for chromosomal abnormalities and genetic disorders. It is typically performed between 15 and 20 weeks of pregnancy. The fluid contains fetal cells and various chemicals produced by the baby, which can be analyzed to detect conditions such as Down syndrome, trisomy 18, and neural tube defects. This test is highly accurate and is often recommended when screening tests like the MSAFP indicate a potential issue.
Choice B rationale
A Nonstress Test (NST) is a non-invasive test that measures the fetal heart rate in response to its movements. It is used to assess fetal well-being, particularly in the third trimester, but it does not provide information about chromosomal abnormalities. The NST is typically used to monitor high-risk pregnancies and to ensure that the fetus is receiving enough oxygen.
Choice C rationale
A Biophysical Profile (BPP) combines an ultrasound with a Nonstress Test to evaluate the fetus’s health. It assesses fetal breathing movements, body movements, muscle tone, amniotic fluid volume, and heart rate reactivity. While it provides a comprehensive assessment of fetal well-being, it does not specifically diagnose chromosomal abnormalities. The BPP is often used in the third trimester to monitor high-risk pregnancies.
Choice D rationale
Chorionic Villus Sampling (CVS) is another diagnostic test that can detect chromosomal abnormalities and genetic disorders. It involves taking a small sample of placental tissue (chorionic villi) for analysis. CVS is typically performed between 10 and 13 weeks of pregnancy, earlier than amniocentesis. While it provides similar diagnostic information, it is not the test of choice following an abnormal MSAFP result, which is usually conducted later in pregnancy.