1 point(s)
Category: Physiological Integrity
As the client reaches 8 cm dilation, the nurse notes late
decelerations on the fetal monitor. The FHR baseline is 165–175
bpm with variability of 0–2bpm. What is the mo
...
1 point(s)
Category: Physiological Integrity
As the client reaches 8 cm dilation, the nurse notes late
decelerations on the fetal monitor. The FHR baseline is 165–175
bpm with variability of 0–2bpm. What is the most likely
explanation of this pattern?
o A. The baby is asleep.
o B. The umbilical cord is compressed.
o C. There is a vagal response.
o D. There is uteroplacental insufficiency.
Correct
Correct Answer: D. There is uteroplacental insufficiency.
This information indicates a late deceleration. This type of
deceleration is caused by uteroplacental lack of oxygen. Late
decelerations are one of the precarious decelerations among the
three types of fetal heart rate decelerations during labor. They
are caused by decreased blood flow to the placenta and can
signify an impending fetal acidemia. • Option A: Has no relation to the readings. The
primary etiology of a late declaration is found to be
uteroplacental insufficiency. Decreased blood flow to
the placenta causes a reduced amount of blood and
oxygen to the fetus. • Option B: Compressed umbilical cord results in a
variable deceleration. The central pathophysiology
behind late deceleration involves uterine contraction
constricting blood vessels in the wall of the uterus
which decreases blood flow through the intervillous
space of the placenta, reducing diffusion of oxygen
into fetal capillaries causing decreased fetal PO2. • Option C: A vagal response is indicative of an early
deceleration. When fetal PO2 decreases,
chemoreceptors initiate an autonomic response in the
fetus causing intense vasoconstriction with increased
blood pressure. The elevated blood pressure is
perceived by the baroreceptors which ultimately
stimulate the parasympathetic system to decrease the
fetal heart rate, causing late deceleration.
14. 14. Question
1 point(s)
Category: Physiological Integrity
The nurse notes variable decelerations on the fetal monitor strip.
The most appropriate initial action would be to:
o A. Notify her doctor
o B. Start an IV
o C. Reposition the client
o D. Readjust the monitor
Incorrect
Correct Answer: C. Reposition the client
The initial action by the nurse observing a late deceleration
should turn the client to the side—preferably, the left side.
Administering oxygen is also indicated. Initial management of
recurrent variable decelerations should have a target of relieving
potential cord compression. Maternal repositioning is a
reasonable first maneuver. Variable decelerations can be seen
resulting from fetal movement if the fetus is premature. • Option A: Notifying the physician might be necessary
but not before turning the client to her side. Recurrent
variable decelerations during labor require evaluation.
Initial evaluation includes characterization of the
decelerations themselves, including their frequency,
depth, and duration. It is also important to assess the
uterine contraction pattern and the other fetal heart
tracing characteristics. • Option B: Starting an IV is not necessary at this time.
In specific clinical scenarios that may result in
concerning variable decelerations, management
should be directed by the etiology of those
decelerations. If a patient is having uterine
tachysystole, reducing the number of contractions by
decreasing oxytocin or administration of a betaagonist may be appropriate. • Option D: Readjusting the fetal monitor is
inappropriate since there is no data to indicate that
the monitor has been applied incorrectly. Electronic
fetal monitoring is utilized in approximately 85% of
live births in the United States, making it the most
common procedure in obstetrics. This frequency
represents an increase since 1980 when its use was
about only 45% of women in labor. Intermittent,
variable decelerations, defined as decelerations
occurring with less than half of contractions, are the
most common fetal heart rate abnormality that takes
place in labor.
15. 15. Question
1 point(s)
Category: Physiological Integrity
Which of the following is a characteristic of a reassuring fetal
heart rate pattern?
o A. A fetal heart rate of 170–180 bpm
o B. A baseline variability of 25–35 bpm
o C. Ominous periodic changes
o D. Acceleration of FHR with fetal movements
Correct
Correct Answer: D. Acceleration of FHR with fetal
movements
Accelerations with movement are normal. Accelerations are
transient increases in the FHR. They are usually associated with
fetal movement, vaginal examinations, uterine contractions,
umbilical vein compression, fet
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