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 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.
Correct Answer is A
Explanation
Choice A rationale
A non-stress test (NST) is a common initial assessment for decreased fetal movement. It evaluates fetal heart rate patterns in response to fetal movements, providing information about fetal well-being and oxygenation.
Choice B rationale
A biophysical profile (BPP) is a more comprehensive assessment that includes an NST and ultrasound evaluation of fetal movements, tone, breathing, and amniotic fluid volume. It may be ordered if the NST results are non-reassuring or if there are other concerns.
Choice C rationale
An ultrasound can provide valuable information about fetal growth, amniotic fluid volume, and placental function. It may be used in conjunction with other tests but is not the first-line assessment for decreased fetal movement.
Choice D rationale
Amniocentesis is an invasive procedure used for specific indications, such as genetic testing or assessing fetal lung maturity. It is not typically used for initial assessment of decreased fetal movement.