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
Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.
Choice B rationale
Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.
Choice C rationale
Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.
Choice D rationale
Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.
Correct Answer is A
Explanation
Choice A rationale
Breech presentation means the fetus’s buttocks or feet are positioned to be delivered first. Fetal heart tones are often heard above the umbilicus in this position.
Choice B rationale
Transverse lie means the fetus is lying horizontally in the uterus. Fetal heart tones would typically be heard at the sides of the abdomen.
Choice C rationale
Cephalic presentation means the fetus’s head is positioned to be delivered first. Fetal heart tones are usually heard below the umbilicus in this position.
Choice D rationale
Oblique lie means the fetus is positioned diagonally in the uterus. Fetal heart tones can be variable depending on the exact position.