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 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 A
Explanation
Choice A rationale
This statement is incorrect because Stage 2 of labor does not involve the delivery of the placenta. Stage 2 starts with the complete dilation and effacement of the cervix and ends with the delivery of the fetus. The delivery of the placenta occurs in Stage 3 of labor.
Choice B rationale
This statement is correct. Stage 2 of labor begins with complete effacement and dilation of the cervix. This stage is characterized by the mother pushing and the eventual delivery of the baby.
Choice C rationale
This statement is also correct. Stage 2 starts when the cervix is fully dilated, allowing the mother to start pushing. This stage continues until the baby is born.
Choice D rationale
This statement is incorrect. Stage 2 ends with the delivery of the fetus, not the placenta. The delivery of the placenta is part of Stage 3 of labor.