38. A client, who is gravida 3, para 1, is at 41 weeks' gestation. The client is 6 cm dilated, 80% effaced, and a –1 station. A nurse is assessing the client's fetal monitor tracing. Which assessment should indicate to the nurse that the fetus is in distress?
. Decelerations in the fetal heart rate during contractions that end when the contraction is over.
. An increase in the fetal heart rate during a vaginal examination.
. A uniform decrease in the heart rate that begins after each contraction for the past four contractions.
. Lack of meconium staining after the amniotic membranes have ruptured.
Test-Taking Tip
When the question describes a fetal monitor pattern, try drawing out the described pattern.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Vital Signs Changes/Abnormalities
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Answer 1 is incorrect because decelerations in the fetal heart rate during contractions that end when the contraction is over are either early decelerations or variable decelerations; neither pattern is indicative of fetal distress. Answer 2 is incorrect because an increase in the fetal heart rate during a vaginal examination indicates fetal well-being and is a reassuring sign. Answer 3 is correct because a uniform decrease in the heart rate that begins after each contraction for the past four contractions describes late decelerations, which is an indication of fetal distress. Answer 4 is incorrect because lack of meconium staining is normal, not an indication of fetal distress.