Chapter 20: Intrapartum Nursing Assessment

The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus? A. Infection B. Umbilical cord compression C. Vagus nerve stimulation D. Hypoxemia

A. Infection Infection is one of the most common causes of fetal tachycardia.

The nurse is caring for a client who has experienced premature rupture of membranes. For which maternal implication(s) should the nurse monitor? Select all that apply. A. Infection B. Preterm labor C. Dyspnea D. Discomfort E. Uterine distention

A. Infection B. Preterm labor

The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? A. Inform the maternal client that the rate is normal. B. Reassess the F H R in 5 minutes because the rate is low. C. Report the F H R to the doctor immediately. D. Turn the maternal client on her side and administer oxygen.

A. Inform the maternal client that the rate is normal.

The nurse is caring for a client undergoing fetal heart rate monitoring, and the F H R is greater than 162 beats/min for 12 minutes. For what cause(s) should the nurse anticipate treatment? Select all that apply. A. Maternal anxiety B. Fetal asphyxia C. Prematurity D. Fetal anemia E. Maternal hypotension

A. Maternal anxiety B. Fetal asphyxia C. Prematurity D. Fetal anemia Maternal anxiety may result in fetal tachycardia. Fetal asphyxia may result in fetal tachycardia. Prematurity may result in fetal tachycardia. Fetal anemia may result in fetal tachycardia.

The nurse is assessing the baseline fetal heart rate for a client in labor. What action should the nurse take first? A. Measure the fetal heart rate for 10 minutes B. Round the heart rate to increments of 5 beats/minute C. Exclude periods of marked variation D. Calculate the mean (average) heart rate

A. Measure the fetal heart rate for 10 minutes

Fetal factors that possibly indicate electronic fetal monitoring include which of the following? Select all that apply. A. Meconium passage B. Multiple gestation C. Preeclampsia D. Grand multiparity E. Decreased fetal movement

A. Meconium passage B. Multiple gestation E. Decreased fetal movement

The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first? A. Perform Leopold maneuvers to determine fetal position. B. Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (U C). C. Dry the maternal abdomen before using the Doppler. D. The diaphragm should be cooled before using the Doppler.

A. Perform Leopold maneuvers to determine fetal position.

The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? A. Woman at 7 c m, fetal heart tones auscultated every 90 minutes B. Woman at 10 c m and pushing, external fetal monitor applied C. Woman with meconium-stained fluid, internal fetal scalp electrode in use D. Woman in preterm labor, external monitor in place

A. Woman at 7 c m, fetal heart tones auscultated every 90 minutes During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough

The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? A. "The monitor is necessary so we can see how your labor is progressing." B. "The monitor will prevent complications from the meconium in your fluid." C. "The monitor helps us to see how the baby is tolerating labor." D. "The monitor can be removed, and oxygen given instead."

C. "The monitor helps us to see how the baby is tolerating labor."

The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? A. Late decelerations B. Early decelerations C. Accelerations D. Fetal dysrhythmia

C. Accelerations

The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? A. The client is assisted into supine position, and the position of the fetus is assessed. B. The upper portion of the uterus is palpated, then the middle section. C. After determining where the back is located, the cervix is assessed. D. Following voiding, the client's abdomen is palpated from top to bottom.

C. After determining where the back is located, the cervix is assessed The cervical exam is not part of Leopold maneuvers. Abdominal palpation is the only technique used for Leopold maneuvers.

The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? A. Blood pressure 120/88 B. Father a carrier of sickle-cell trait C. Dark red vaginal bleeding D. History of domestic abuse

C. Dark red vaginal bleeding Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus.

Persistent early decelerations are noted. What would the nurse's first action be? A. Turn the mother on her left side and give oxygen. B. Check for prolapsed cord. C. Do nothing. This is a benign pattern. D. Prepare for immediate forceps or cesarean delivery.

C. Do nothing. This is a benign pattern.

The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? A. Moderate variability B. Early decelerations C. Late decelerations D. Accelerations

C. Late decelerations

The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? A. Early decelerations with each contraction B. Variable decelerations that recover to the baseline C. Late decelerations with minimal variability D. Accelerations

C. Late decelerations with minimal variability

After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? A. Increase the mother's oxygen rate. B. Turn the mother to the left lateral position. C. Prepare the mother for a higher-risk delivery. D. Increase the intravenous infusion rate

C. Prepare the mother for a higher-risk delivery.

The nurse has just palpated contractions and compares the consistency to that of the forehead in order to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? A. Mild B. Moderate C. Strong D. Weak

C. Strong

After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? A. Breech presentation B. Uteroplacental insufficiency C. Compression of the fetal head D. Umbilical cord compression

D. Umbilical cord compression

The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? A. Assist the client to change position. B. Apply oxygen to the client at 2 liters per nasal cannula. C. Notify the operating room of the need for a cesarean birth. D. Determine the color of the leaking amniotic fluid

A. Assist the client to change position. The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman.

The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? A. Document the fetal heart rate. B. Apply oxygen via mask at 10 liters. C. Prepare for imminent delivery. D. Assist the client into Fowler's position.

A. Document the fetal heart rate.

Upon assessing the F H R tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Select all that apply. A. Early fetal hypoxia B. Prolonged fetal stimulation C. Fetal anemia D. Fetal sleep cycle E. Infection

A. Early fetal hypoxia B. Prolonged fetal stimulation C. Fetal anemia E. Infection

Before performing Leopold maneuvers, what would the nurse do? Select all that apply. A. Have the client empty her bladder. B. Place the client in Trendelenburg position. C. Have the client lie on her back with her feet on the bed and knees bent. D. Turn the client to her left side.

A. Have the client empty her bladder. C. Have the client lie on her back with her feet on the bed and knees bent.

The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? A. "I stimulated the top of the fetus's head to wake him up a little." B. "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." C. "I stimulated the top of the fetus's head to calm the fetus down before birth." D. "I stimulated the top of the fetus's head to find out whether he is in distress."

B. "I stimulated the top of the fetus's head to try to get his heart rate to accelerate."

A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? A. "The most important part of fetal heart monitoring is the absence of variable decelerations." B. "The most important part of fetal heart monitoring is the presence of variability." C. "The most important part of fetal heart monitoring is the fetal heart rate baseline." D. "The most important part of fetal heart monitoring is the depth of decelerations."

B. "The most important part of fetal heart monitoring is the presence of variability."

The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status? A. "How did you decide to have your baby at this hospital?" B. "Who will be your labor support person?" C. "Have you chosen names for your baby yet?" D. "What feeding method will you use for your baby?"

B. "Who will be your labor support person?"

A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? A. Change the client's position in bed. B. Notify the physician that birth is imminent. C. Administer oxygen at 2 liters per minute. D. Begin continuous fetal heart rate monitoring.

D. Begin continuous fetal heart rate monitoring. Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring.