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

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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 [Show More]

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