Author Question: The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic ... (Read 94 times)

Arii_bell · **on:** Jun 28, 2018

The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action?

a. Administer oxygen with a face mask at 8 to 10 L/min.
b. Reposition the fetal monitor ultrasound transducer.
c. Assist the client to the bathroom to empty her bladder .
d. Continue to monitor the client and fetal heart rate patterns.

Question 2

The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which are the components of this tool? (Select all that apply.)

a. Color
b. Moro reflex
c. Oxygen saturation
d. Posture of arms and legs
e. Sleeplessness
f. Facial expression

brbarasa · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. They reflect possible impaired placental exchange (uteroplacental insufficiency). Administration of 100 oxygen through a snug face mask makes more oxygen available for transfer to the fetus. A commonly suggested rate is 8 to 10 L/min. The pattern is nonreassuring so repositioning the fetal ultrasound transducer, assisting the client to the bathroom, or continuing to monitor the pattern will not correct the problem.

Answer to Question 2

ANS: C, E, F
Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.