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
Variable decelerations are not related to the use of narcotic analgesics. Narcotic analgesics can cause other fetal heart rate changes, such as decreased variability, but they do not cause variable decelerations.
Choice B rationale
Variable decelerations are due to umbilical cord compression. This is the correct interpretation. Umbilical cord compression can lead to transient decreases in fetal blood flow and oxygenation, resulting in variable decelerations on the fetal monitor tracing.
Choice C rationale
Variable decelerations are not caused by maternal hypotension. Maternal hypotension can lead to late decelerations due to uteroplacental insufficiency, but it does not cause variable decelerations.
Choice D rationale
Variable decelerations are not indicative of fetal hypoxia. While severe and persistent variable decelerations can lead to fetal hypoxia, the primary cause of variable decelerations is umbilical cord compression.
Correct Answer is B
Explanation
Choice A rationale
Providing ice chips or mouth swabs can help keep the client comfortable and hydrated, but it is not the priority action when administering pain medication.
Choice B rationale
Assessing and documenting maternal vital signs and fetal heart rate after administering Fentanyl is crucial. This ensures that the medication is not causing any adverse effects on the mother or fetus and that both are stable.
Choice C rationale
Dimming the lights and providing a quiet atmosphere can help create a calming environment, but it is not the priority action when administering pain medication.
Choice D rationale
Assisting the patient with coping skills, including breathing techniques, is important for managing pain, but it is not the priority action when administering pain medication.