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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?

A.

Early decelerations.

B.

Late decelerations.

C.

Variable decelerations.

D.

Prolonged decelerations.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

Choice A rationale

While a negative result in a Contraction Stress Test (CST) is desirable, this choice does not fully explain the significance of the result. A negative CST indicates that there are no late decelerations in the fetal heart rate in response to uterine contractions, suggesting that the fetus can handle the stress of labor.

Choice B rationale

This choice describes the criteria for a reactive Nonstress Test (NST), not a Contraction Stress Test (CST). In a CST, the focus is on the fetal heart rate response to contractions, not the number of contractions or variability.

Choice C rationale

A negative result in a CST indicates fetal well-being, meaning that the fetus can tolerate the stress of uterine contractions without showing signs of distress, such as late decelerations in the heart rate. This result suggests that the fetus is likely to handle labor well.

Choice D rationale

A positive result in a CST indicates that the fetus has late decelerations in response to contractions, which can be a sign of fetal distress. This result may suggest fetal growth restriction, lower Apgar scores, and the potential need for cesarean delivery. However, this choice does not fully capture the significance of a positive CST result.

Correct Answer is A

Explanation

Choice A rationale

Monitoring the fetal heart rate is the next appropriate action. The fetal heart rate provides crucial information about the fetus’s well-being and can help identify any potential issues that may need further intervention.

Choice B rationale

Monitoring uterine contractions is important, but in this scenario, the client’s vital signs are stable, and there is no indication of labor. Therefore, monitoring the fetal heart rate takes precedence.

Choice C rationale

Amniotic fluid levels are important to monitor, but they are typically assessed through ultrasound rather than immediate bedside monitoring. The fetal heart rate provides more immediate information about the fetus’s condition.

Choice D rationale

Cervical dilation is relevant during labor, but there is no indication that the client is in labor based on the provided vital signs. Monitoring the fetal heart rate is more pertinent in this situation.

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