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When interpreting a fetal monitoring tracing, which of the following findings would require the nurse to intervene?

A.

Presence of late decelerations.

B.

Variability in fetal heart rate of 12 bpm.

C.

Accelerations in fetal heart rate.

D.

Baseline fetal heart rate of 140 bpm.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia. They occur after the peak of a contraction and indicate that the fetus is not receiving enough oxygen. This requires immediate intervention to improve fetal oxygenation and prevent fetal distress.

 

Choice B rationale

 

Variability in fetal heart rate of 12 bpm is considered moderate variability, which is a reassuring sign of fetal well-being. It indicates that the fetus has a healthy autonomic nervous system and is not in distress.

 

Choice C rationale

 

Accelerations in fetal heart rate are also a reassuring sign. They indicate that the fetus is well-oxygenated and responding appropriately to stimuli. No intervention is needed for accelerations.

 

Choice D rationale

 

A baseline fetal heart rate of 140 bpm is within the normal range (110-160 bpm) and does not indicate any immediate concern. It is a sign of a healthy, well-oxygenated fetus.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

This statement is incorrect. Vagus nerve stimulation actually decreases FHR variability. The vagus nerve, part of the parasympathetic nervous system, slows the heart rate and reduces variability.

Choice B rationale

This statement is correct. Baroreceptors are sensors located in blood vessels that help regulate blood pressure by detecting changes in the stretch of the vessel walls. They play a crucial role in maintaining stable blood pressure levels.

Choice C rationale

This statement is correct. The autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems, controls the fetal heart rate. It regulates the balance between heart rate acceleration and deceleration.

Choice D rationale

This statement is correct. Chemoreceptors respond to changes in blood gas levels, such as oxygen and carbon dioxide. They help regulate respiratory and cardiovascular responses to maintain homeostasis.

Correct Answer is C

Explanation

Choice A 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.

Choice B 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 C 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 D 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.

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