NCLEX RN COMPREHENSIVE EXIT EXAMS WITH NGN LATEST MULTIPLE VERSIONS COMBINED LATEST UPDATE 2023-2024

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, fetal scalp stimulation or even external acoustic stimulation. The presence of accelerations is considered a reassuring sign of fetal well-being. • Option A: The average fetal heart rate is between 110 and 160 beats per minute. The normal FHR range is between 120 and 160 beats per minute (bpm). The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. Prematurity, maternal anxiety and maternal fever may increase the baseline rate, while fetal maturity decreases the baseline rate. • Option B: Baseline variability is defined as fluctuations in the fetal heart rate of more than 2 cycles per minute. Marked variability is at >25 BPM. The FHR is under constant variation from the baseline. This variability reflects a healthy nervous system, chemoreceptors, baroreceptors and cardiac responsiveness. Prematurity decreases variability; therefore, there is little rate fluctuation before 28 weeks. Variability should be normal after 32 weeks. • Option C: If there are ominous periodic changes, it would indicate an abnormality in the fetal heart rate pattern. Fetal hypoxia, congenital heart anomalies and fetal tachycardia also cause decreased variability. Beat-to-beat or short-term variability is the oscillation of the FHR around the baseline in amplitude of 5 to 10 bpm. Long-term variability is a somewhat slower oscillation in heart rate and has a frequency of three to 10 cycles per minute and an amplitude of 10 to 25 bpm.