QUESTION: "A client whose cervix is 10 cm dilated begins to push. The nurse notes early decelerations of the fetal heart rate. Which of the following would the nurse anticipate as the most likely cause of this fetal heart rate pattern?"
CHOICES
( X ) a.) Cord compression.
( X ) b.) Fetal bradycardia.
( O ) c.) Fetal head compression.
( X ) d.) Inadequate uteroplacental perfusion.
RATIONALE: Early decelerations are usually due to pressure on the fetal head as the fetus progresses through the birth canal. These decelerations mirror the contraction pattern and are usually benign, unless the pattern occurs in early labor. If this pattern is demonstrated in early labor, it may indicate cephalopelvic disproportion. Variable decelerations are associated with cord compression. Fetal bradycardia may occur as a result of analgesia and can occur at any time. Inadequate placental perfusion is associated with late fetal heart rate decelerations. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
