Nokea
The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.)
- A. Post-term fetus
- B. Maternal fever
- C. Placenta previa
- D. Induction of labor
Correct Answer: A
Rationale: A. Post-term fetus: Fetal scalp stimulation can be contraindicated in post-term fetuses due to the potential risks associated with uterine hyperstimulation and decreased fetal reserve in these pregnancies.
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Proper placement of the tocotransducer for electronic fetal monitoring is
- A. Inside the uterus.
- B. On the fetal scalp.
- C. Over the uterine fundus.
- D. Over the mother's lower abdomen.
Correct Answer: C
Rationale: The tocotransducer is a device used for electronic fetal monitoring to measure uterine contractions. Proper placement of the tocotransducer is over the uterine fundus, which is the upper part of the uterus where contractions are most accurately detected. Placing the tocotransducer there allows for optimal monitoring of uterine activity during labor, ensuring accurate readings and appropriate interventions if necessary. Placing the tocotransducer inside the uterus, on the fetal scalp, or over the mother's lower abdomen would not provide accurate readings of uterine contractions.
What is the most likely cause for this fetal heart rate pattern?
- A. Administration of an epidural for pain relief during labor
- B. Cord compression
- C. Breech position of fetus
- D. Administration of meperidine (Demerol) for pain relief during labor
Correct Answer: B
Rationale: The fetal heart rate pattern described in the question, which likely includes decelerations, is indicative of cord compression. Cord compression occurs when there is pressure on the umbilical cord, leading to temporary reduction or blockage of blood flow and oxygen supply to the fetus. This can result in variable decelerations in the fetal heart rate pattern. Common scenarios that can cause cord compression include changes in fetal position, cord prolapse, or excessive uterine contractions. It is important to promptly address cord compression to prevent fetal distress and potential complications during labor and delivery. The other options listed may also influence fetal heart rate, but in this scenario, cord compression is the most likely cause based on the described heart rate pattern.
A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action?
- A. Stop the infusion of Pitocin.
- B. Reposition the patient from her right to her left side
- C. Perform a vaginal exam to assess for a prolapsed cord
- D. Perform a vaginal exam to assess for a prolapsed cor
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to stop the infusion of Pitocin. Late decelerations are a concerning fetal heart rate pattern that indicates uteroplacental insufficiency. Oxytocin (Pitocin) can cause hyperstimulation of the uterus, leading to poor oxygenation of the fetus and resulting in late decelerations. Stopping the Pitocin infusion can help to improve placental perfusion and oxygenation to the fetus, potentially reversing the late decelerations. It is crucial to address the fetal distress promptly to prevent further compromise and ensure the safety of both the mother and the baby. Other interventions, such as repositioning the patient or preparing for a cesarean birth, may also be necessary but should occur after stopping the Pitocin infusion.
What is a sign of fetal distress?
- A. prolonged moderate variability
- B. accelerations
- C. repetitive late decelerations
- D. variable decelerations
Correct Answer: C
Rationale: Fetal distress can be indicated by repetitive late decelerations, which show a lack of oxygen during labor.
A patient is being prepared for an unplanned cesarean section. Which pre-procedure information is most important for the nurse to report before the administration of regional anesthesia?
- A. Hypovolemia corrected with IV fluid administration
- B. Inability of the patient to sit on the bedside and flex forward
- C. Laboratory value indicating a low platelet count
- D. History of patient experiencing headaches after a spinal
Correct Answer: C
Rationale: Choice C is the correct answer because a low platelet count indicates a risk for bleeding, and regional anesthesia can be dangerous in such cases due to the possibility of epidural or spinal hematoma.