Chapter 10

A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process? a. Auscultating the fetal heart b. Obtaining an obstetric history c. Determining when the last meal was eaten d. Ascertaining whether the membranes have ruptured

a. Auscultating the fetal heart

A client's membranes rupture while her labor is being augmented with an Oxycontin infusion. A nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next? a. Change the client's position b. Take the client's blood pressure c. Stop the client's oxytocin infusion d. Prepare the client for an immediate birth

a. Change the client's position

What is a common problem that confronts the client in labor when an external fetal monitor has been applied to her abdomen? a. Intrusion on movement b. Inability to take sedatives c. Interference with breathing techniques d. Increased frequency of vaginal examinations

a. Intrusion on movement

During labor, a nurse identifies that there is an early fetal heart rate deceleration. How many fetal heartbeats/min were there early in the contraction that indicated to the nurse that the deceleration occurred? a. 80-100 b. 100-120 c. 120-140 d. 140-160

b. 100-120

A client in labor begins to experience contractions 2 to 3 mins apart that last about 45 secs. Between contractions the nurse identifies a fetal heart rate of 100 beats/min on the internal fetal monitor. What us the next nursing action? a. Notify the health care provider b. Resume continuous fetal heart monitoring c. Continue to monitor the maternal vital signs d. Document the fetal heart rate as an expected response to contractions

a. Notify the health care provider

A 36-year-old primigravida, accompanied by her husband, is admitted to the birthing unit at 39 weeks gestation. External fetal monitoring is instituted. What should the nurse consider when a fetus is being monitored? a. The machinery may be frightening to a laboring couple b. Internal monitoring will be used in the latter part of labor c. The mother will be given mild sedatives as labor progresses d. Older primigravidas are more concerned about labor than younger women

a. The machinery may be frightening to a laboring couple

An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place? a. The most comfortable position can be assumed b. Monitoring is more accurate in the side-lying position c. The monitor leads can be detached when sitting on the bedpan d. Maintaining a supine position holds the internal electrode in place

a. The most comfortable position can be assumed

During labor, a client has an internal fetal monitor applied. What fetal heart rate should most concern the nurse? a. Does not drop during contractions b. Varies from 30-140 bpm c. Drops to 110 bpm during a contraction d. Returns to baseline heart rate after a contraction ends

d. Returns to baseline heart rate after a contraction ends

When monitoring the FHR of a client in labor, the nurse identifies an elevation of 15 beats more than the baseline rate of 135 beat/min lasting for 15 seconds. How should the nurse document this event? a. An acceleration b. An early elevation c. A sonographic motion d. A tachycardic heart rate

a. An acceleration

A nurse is observing a reading on the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression? a. Smooth, flat baseline tracings of 135 bpm b. Abrupt decreases in fetal heart rate that are unrelated to the contractions c. Accelerations in the fetal heart rate of 10 beats per min above baseline d. Decelerations when a contraction begins that return to baseline when the contraction ends

b. Abrupt decreases in fetal heart rate that are unrelated to the contractions

At 38 weeks' gestation, a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm, with contractions occurring every 4 mins & lasting 45 secs. What dies the nurse conclude is the cause of these late decelerations? a. Imminent vaginal birth b. Uteroplacental insufficiency c. Pattern of nonprogressive labor d. Reassuring response to contractions

b. Uteroplacental insufficiency

After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler be placed to best auscultate fetal heart tones? a. Above the umbilicus in the midline b. Above the umbilicus on the left side c. Below the umbilicus on the right side d. Below the umbilicus near the left groin

c. Below the umbilicus on the right side

A client in active labor has an external fetal monitor in place. Using the monitor strip below, identify the correct assessment a. Tetanic contractions b. Marked FHR variability c. FHR baseline at 150 beats/min d. Contractions lasting 130 seconds

c. FHR baseline at 150 beats/min

An external monitor is placed on the abdomen of a client admitted in active labor. The nurse identifies that during each contraction, the fetal heart rate decelerates as the contraction peaks. what should the nurse do next? a. Help the client to knee-chest position to avoid cord compression b. Notify the health care provider because pf the possible head compression c. Monitor the fetal heart rate until it returns to baseline when the contractions ends d. Place the client in a semi-Fowler position to prevent compression of the vena cava.

c. Monitor the fetal heart rate until it returns to baseline when the contractions ends