Examkin

Question

Difficulty: HardAnte/Intra/Postpartum and Newborn Care

A nurse is evaluating the electronic fetal monitoring tracing of a client at 39 weeks gestation who is in active labor. The client has not received any systemic medications. The tracing reveals a baseline fetal heart rate of 135 beats/min. Over the past 25 minutes, the tracing demonstrates a smooth, undulating, sine wave-like pattern with an amplitude of 15 beats/min and a frequency of 4 cycles per minute. There are no accelerations, and baseline variability is absent. Which action is the priority for the nurse?

  1. Notify the healthcare provider immediately and prepare for an expedited delivery.Answer
  2. B
    Administer an intravenous fluid bolus and position the client in a lateral tilt.
  3. C
    Prepare the necessary equipment to initiate a prescribed amnioinfusion.
  4. D
    Document the pattern as a benign physiologic variant and continue routine monitoring.

Answer

The priority action is to immediately notify the healthcare provider and prepare for an expedited delivery due to the presence of a Category III true sinusoidal fetal heart rate pattern.
The description of a smooth, undulating, sine wave-like pattern with absent baseline variability is the definition of a true sinusoidal fetal heart rate pattern. This is a Category III tracing that indicates severe fetal hypoxia, acidosis, or severe fetal anemia (such as from fetal-maternal hemorrhage). It is an obstetric emergency that requires immediate notification of the healthcare provider and preparation for an expedited (usually cesarean) delivery.

Step-by-Step Solution

1
Analyze the fetal heart rate (FHR) tracing characteristics described in the stem.
The tracing shows a smooth, undulating, sine wave-like pattern with an amplitude of 15 beats/min, a frequency of 4 cycles per minute, and absent baseline variability.
Accurate identification of FHR patterns is required to determine fetal well-being and categorize the tracing.
2
Correlate the FHR characteristics with standard NCLEX definitions.
The findings define a true sinusoidal FHR pattern, which is a Category III (abnormal) tracing.
A sinusoidal pattern indicates severe fetal derangement, most commonly severe fetal anemia (e.g., from Rh alloimmunization or vasa previa rupture), severe hypoxia, or acidosis.
3
Determine the priority nursing intervention based on the tracing category.
Because this is a life-threatening Category III tracing and not a Category II tracing (which might respond to intrauterine resuscitation), the priority is immediate medical intervention and preparation for emergency delivery.
Delaying delivery for standard resuscitative measures or observation in the presence of a true sinusoidal pattern can result in fetal demise.

Key Concept

A true sinusoidal fetal heart rate pattern is a Category III tracing indicating severe fetal anemia or hypoxia, requiring immediate notification of the provider and emergency delivery.
Rate this question

Topics

Ante/Intra/Postpartum and Newborn Care

More questions from this topic