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 C
Explanation
Choice A rationale
Keeping four side rails up is a safety measure to prevent falls, but it is not specific to the care of a client in active labor. It is a general safety precaution used for clients who are at risk of falling or have impaired mobility.
Choice B rationale
Inserting an indwelling urinary catheter is not a routine action for a client in active labor. Catheterization is typically reserved for specific medical indications, such as urinary retention or the need for accurate urine output measurement in certain high-risk situations.
Choice C rationale
Checking the cervix prior to administering medication is crucial in active labor. This ensures that the medication is appropriate for the stage of labor and helps avoid complications such as administering pain relief too early or too late, which could affect labor progression and fetal well-being.
Choice D rationale
Monitoring the fetal heart rate (FHR) every hour is important, but it may not be frequent enough in active labor. Continuous or more frequent monitoring is often required to promptly detect any signs of fetal distress and take appropriate actions.
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.