Difficulty: Medium
Average Score: 68%
Simulated
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain the decreased variability is most likely caused by which of the following?
Correct answer
D
Rationale
Nalbuphine, an opioid, can reduce fetal heart rate variability by depressing the central nervous system, a common side effect. Maternal fatigue, malposition, or small-for-gestational-age fetus are less likely causes.