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Difficulty: EasyAnte/Intra/Postpartum and Newborn Care

A nurse is evaluating the electronic fetal monitor tracing of a client in active labor. Which of the following findings indicate a potential complication and require immediate nursing intervention? Select all that apply.

  1. A
    Early decelerations that mirror the onset and recovery of uterine contractions
  2. Late decelerations occurring consistently after the peak of most contractionsAnswer
  3. Baseline fetal heart rate of 175 beats per minute over a 20-minute periodAnswer
  4. D
    Moderate baseline fetal heart rate variability of 10 to 15 beats per minute
  5. Abrupt variable decelerations that drop to 60 beats per minute and last for 70 secondsAnswer
  6. F
    Accelerations of 15 beats per minute above the baseline lasting for 15 seconds

Answer

The findings requiring immediate intervention are late decelerations, a baseline heart rate of 175 beats per minute, and abrupt severe variable decelerations.
Late decelerations, fetal tachycardia (heart rate consistently over 160 bpm), and severe variable decelerations are nonreassuring patterns indicating potential fetal compromise, such as hypoxia, infection, or severe umbilical cord compression. These findings necessitate immediate nursing interventions like maternal repositioning, administering oxygen, and notifying the healthcare provider.

Step-by-Step Solution

1
Evaluate the baseline fetal heart rate and variability.
A rate of 175 bpm is tachycardia (abnormal), while moderate variability of 10 to 15 bpm is normal.
The normal baseline fetal heart rate is 110-160 bpm with moderate variability. Tachycardia requires intervention.
2
Analyze the presence and timing of any decelerations.
Early decelerations are benign. Late decelerations and severe variable decelerations are abnormal findings.
Late decelerations indicate uteroplacental insufficiency, and severe variables indicate significant cord compression; both require immediate action.
3
Assess for the presence of accelerations.
Accelerations of 15 bpm for 15 seconds are present and represent a normal finding.
Accelerations indicate a well-oxygenated fetus with an intact nervous system.

Key Concept

Interpretation of Fetal Heart Rate (FHR) Patterns
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Topics

Ante/Intra/Postpartum and Newborn Care

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