Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
42. A client is admitted to labor and delivery with a diagnosis of placental abruption. A nursing priority for this client is to minimize alterations in fetal tissue perfusion. A nurse recognizes that this goal has been met when which finding is noted?
. Presence of accelerations.
. Consistent decreased fetal heart rate variability.
. Evidence of prolonged fetal bradycardia.
. Presence of consistent late decelerations.
Test-Taking Tip
The priority for this client is fetal well-being; consider which of the patterns are indicative of good oxygenation.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because accelerations are an indication of fetal well-being and a well-oxygenated fetus. Answer 2 is incorrect because consistent decreased fetal heart rate variability is an indicator of decreased placental perfusion and poor oxygenation. Answer 3 is incorrect because prolonged fetal bradycardia is an indicator of decreased placental perfusion and fetal distress. Answer 4 is incorrect because consistent late decelerations are an indicator of poor uteroplacental perfusion and fetal distress.