When interpreting a fetal monitoring tracing, which of the following findings would require the nurse to intervene?
Presence of late decelerations.
Variability in fetal heart rate of 12 bpm.
Accelerations in fetal heart rate.
Baseline fetal heart rate of 140 bpm.
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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Correct Answer is A
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.
Choice B rationale
Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.
Choice C rationale
Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.
Choice D rationale
Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.