Health Promotion and Maintenance
85. A client, who is gravida 3, para 2, is 8 cm dilated, 100% effaced, and a 0 station. When evaluating the fetal monitor tracing, a nurse notes baseline heart rate 170 bpm, minimal variability, and consistent late decelerations. What is the most likely explanation of this pattern?
. The fetus is asleep.
. The umbilical cord is compressed.
. There is a head compression.
. There is uteroplacental insufficiency.
Test-Taking Tip
Picture the fetal heart tracing and the physiology behind each of the patterns. Evaluate a fetal heart rate tracing the same way every time: baseline, variability, accelerations, and finally, decelerations.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Health Promotion and Maintenance
.
Answer 1 is incorrect because fetal sleep can manifest as minimal variability—but this fetus also has tachycardia and late decelerations, which are not associated with fetal sleep. Answer 2 is incorrect because umbilical cord compression is manifested by variable decelerations, not late decelerations or tachycardia. Answer 3 is incorrect because head compressions are early decelerations that mirror the contractions, not late decelerations or tachycardia. Answer 4 is correct because late decelerations are indicative of uteroplacental insufficiency, and tachycardia can be a sign of hypoxia as well.