Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
20. A client, who is gravida 3, para 1, is 6 cm dilated, 80% effaced, and a 0 station. The external fetal monitor shows baseline heart rate of 145 bpm, moderate variability, and variable decelerations. What are appropriate nursing interventions for this client? Select all that apply.
. Perform a sterile vaginal exam.
. Change the client's position.
. Prepare the client for an emergency cesarean delivery.
. Administer a fluid bolus.
. Prepare for a vacuum-assisted delivery.
Test-Taking Tip
Variable decelerations are caused by umbilical cord compression; think about interventions that can relieve umbilical cord compression. Eliminate the two answers that "prepare" for procedures when the information supplied is not indicative of a problem and/or the client is not ready for the procedure ("vacuum-assisted delivery").
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. . .
Answer 1 is correct because performing a sterile vaginal examination will eliminate the possibility of a prolapsed umbilical cord that may be causing the variable decelerations. Answer 2 is correct because changing the client's position can help alleviate cord compression that could be causing the variable decelerations. Answer 3 is incorrect because variable decelerations in the presence of moderate variability and a normal fetal heart rate baseline is not indicative of fetal distress, and does not require an emergency cesarean section. Answer 4 is correct because administering a fluid bolus can increase hydration and decrease the variable decelerations that may be caused by cord compression. Answer 5 is incorrect because the client is not completely dilated and is not ready for a vacuum-assisted delivery.