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
Dizziness can be a side effect of epidural anesthesia, but it is not as critical as hypotension. It should be monitored, but it does not require immediate reporting unless it is severe or accompanied by other symptoms.
Choice B rationale
Blood pressure of 88/52 mmHg indicates hypotension, which is a common and potentially serious side effect of epidural anesthesia. Hypotension can lead to decreased placental perfusion and fetal distress, so it requires immediate attention and reporting to the anesthesia provider.
Choice C rationale
A pain level of 1 on a 0 to 10 scale indicates that the epidural is effectively managing the client’s pain. This is a positive outcome and does not require reporting.
Choice D rationale
A pulse of 88 bpm is within the normal range for an adult and does not indicate any immediate concern that needs to be reported to the anesthesia provider.
Correct Answer is A
Explanation
Choice A rationale
A non-stress test (NST) is a common test used to evaluate fetal well-being, especially in cases of decreased fetal movement. It measures the fetal heart rate in response to its movements. A reactive NST, where the fetal heart rate increases with movement, indicates good oxygenation and neurological function.
Choice B rationale
A contraction stress test (CST) evaluates the fetal heart rate response to uterine contractions, which can be induced by oxytocin or nipple stimulation. It is typically used to assess placental function and fetal tolerance to labor, not for initial assessment of decreased fetal movement.
Choice C rationale
A biophysical profile (BPP) combines an NST with ultrasound to assess fetal breathing, movement, tone, and amniotic fluid volume. While comprehensive, it is more time-consuming and usually reserved for further evaluation if the NST is non-reactive.
Choice D rationale
An ultrasound can assess fetal growth, amniotic fluid volume, and anatomical structures. However, it does not provide real-time information on fetal heart rate reactivity, making it less suitable for immediate assessment of decreased fetal movement.