The nurse observes variable decelerations on the fetal monitor tracing.
Which of the following is a correct interpretation of this finding?
Variable decelerations are related to the use of narcotic analgesics.
Variable decelerations are due to umbilical cord compression.
Variable decelerations are caused by maternal hypotension.
Variable decelerations are indicative of fetal hypoxia.
The Correct Answer is B
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.
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Correct Answer is B
Explanation
Choice A rationale
The presenting part being 2 cm below the ischial spines would be documented as +2 station, indicating that the fetal head is descending well into the pelvis.
Choice B rationale
The presenting part being 2 cm above the ischial spines is correctly documented as -2 station. This indicates that the fetal head is still relatively high in the pelvis and has not yet descended to the level of the ischial spines.
Choice C rationale
The presenting part being at the level of the ischial spines is documented as 0 station. This is the midpoint of the pelvis and indicates that the fetal head is engaged.
Choice D rationale
The presenting part being 2 cm below the cervix is not a standard way to describe fetal station. Station is measured relative to the ischial spines, not the cervix.
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to walk around for 30 minutes and then resume monitoring is not the most appropriate action in this scenario. Walking may help stimulate fetal movement, but it is not the first-line intervention when there are no accelerations or fetal movement during a nonstress test. The nurse should try other methods to stimulate fetal movement before resorting to walking.
Choice B rationale
Performing vibroacoustic stimulation is the correct action. Vibroacoustic stimulation involves using a device to produce a sound and vibration near the maternal abdomen to stimulate fetal movement and heart rate accelerations. This method is non-invasive and can help determine fetal well-being by eliciting a response from the fetus.
Choice C rationale
Immediately reporting the situation to the provider and preparing the client for induction of labor is premature. The absence of accelerations or fetal movement during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions, such as vibroacoustic stimulation, should be attempted first.
Choice D rationale
Repositioning the client into a supine position is not recommended. The supine position can lead to supine hypotensive syndrome, which can decrease blood flow to the fetus. The nurse should avoid placing the client in a supine position and instead try other methods to stimulate fetal movement.