Mother Baby: Chapter 15, 16, and 17
The nurse providing care for the laboring woman should understand that accelerations with fetal movement: A. Are reassuring B. Are caused by umbilical cord compression C. Warrant close observation D. Are caused by uteroplacental insufficiency
A A. Correct: Episodic accelerations in the FHR occur during fetal movement and are indications of fetal well-being. B. Incorrect: Umbilical cord compression results in variable decelerations in the FHR. C. Incorrect: Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. D. Incorrect: Uteroplacental insufficiency would result in late decelerations in the FHR. p. 504
The nurse providing care for the laboring woman comprehends that accelerations with fetal movement: a. Are reassuring. b. Are caused by umbilical cord compression. c. Warrant close observation. d. Are caused by uteroplacental insufficiency.
A Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.
Fetal well-being during labor is assessed by: a. The response of the fetal heart rate (FHR) to uterine contractions (UCs). b. Maternal pain control. c. Accelerations in the FHR. d. An FHR above 110 beats/min.
A Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR above 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information would be needed to determine fetal well-being.
Women who have participated in childbirth education classes often bring a "birth bag" or "Lamaze bag" with them to the hospital. These items often assist in reducing stress and providing comfort measures. The nurse caring for women in labor should be aware of common items that a client may bring, including (Select all that apply): a. Rolling pin. b. Tennis balls. c. Pillow. d. Stuffed animal or photo. e. Candles.
A, B, C, D
A normal uterine activity (UA) pattern in labor is characterized by: A. Contractions every 2 to 5 minutes B. Contractions lasting about 2 minutes C. Contractions about 1 minute apart D. A contraction intensity of about 1000 mm Hg with relaxation at 50 mm Hg
AContractions normally occur every 2 to 5 minutes and last less than 90 seconds (intensity 800 mm Hg) with about 30 seconds in between (20 mm Hg or less).
Which deceleration of the FHR would NOT require the nurse to change the maternal position? A. Early decelerations B. Late decelerations C. Variable decelerations D. It is always a good idea to change the woman's position.
AEarly decelerations (and accelerations) generally do not need any nursing intervention.
The nurse caring for the laboring woman should understand that early deceleration are caused by:
Altered fetal cerebral blood flow. [Early decelerations are the fetus's response to fetal head compression]
The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?
Assessing for chest discomfort and palpitations. - Terbutaline is a 2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations.
The nurse providing care for the laboring woman should understand that variable FHR decelerations are caused by: A. Altered fetal cerebral blood flow B. Umbilical cord compression C. Uteroplacental insufficiency D. Fetal hypoxemia
B A. Incorrect: Altered fetal cerebral blood flow would result in early decelerations in the FHR. B. Correct: Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord. C. Incorrect: Uteroplacental insufficiency would result in late decelerations in the FHR. D. Incorrect: Fetal hypoxemia would result in tachycardia initially, then bradycardia if hypoxia continues. p. 507
During labor a fetus with an average heart rate of 135 beats/min over a 10-minute period would be considered to have: a. Bradycardia. c. Tachycardia. b. A normal baseline heart rate. d. Hypoxia.
B The baseline heart rate is measured over 10 minutes; a normal range is 110 to 160 beats/min. Bradycardia is a fetal heart rate (FHR) below 110 beats/min for 10 minutes or longer. Tachycardia is an FHR over 160 beats/min for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of this condition exists with a baseline heart rate in the normal range.
The nurse providing care for the laboring woman realizes that variable fetal heart rate (FHR) decelerations are caused by: a. Altered fetal cerebral blood flow. c. Uteroplacental insufficiency. b. Umbilical cord compression. d. Fetal hypoxemia.
B Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the FHR. Fetal hypoxemia would result in tachycardia initially and then bradycardia if hypoxia continues.
What three measures should the nurse implement to provide intrauterine resuscitation? Select the best response that indicates the priority of actions that should be taken, starting with the most important. A. Call the provider, reposition the mother, and perform a vaginal exam B. Reposition the mother, increase IV fluid, and provide oxygen via face mask C. Administer oxygen to the mother, increase IV fluid, and notify the care provider D. Perform a vaginal exam, reposition the mother, and provide oxygen via face mask
B These are the correct nursing actions for intrauterine resuscitation.
A new client and her partner arrive on the labor, delivery, recovery, and postpartum (LDRP) unit for the birth of their first child. You apply the EFM to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby's heart rate should be. Your best response is: A. "Don't worry about that machine; that's my job." B. "The top line graphs the baby's heart rate. Generally, the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor." C. "The top line graphs the baby's heart rate, and the bottom line lets me know how strong the contractions are." D. "Your doctor will explain all of that later."
B This statement educates the partner about fetal monitoring and provides support and information to alleviate his fears.
A tiered system of categorizing FHR has been recommended by regulatory agencies. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. These categories include (Select all that apply): a. Reassuring. b. Category I. c. Category II. d. Nonreassuring. e. Category III.
B, C, E The three tiered system of FHR tracings include Category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate. This category includes tracings that do not meet Category I or III criteria. Category III tracings are abnormal and require immediate intervention.
The nurse providing care for the laboring woman should understand that late FHR decelerations are caused by: A. Altered cerebral blood flow B. Umbilical cord compression C. Uteroplacental insufficiency D. Meconium fluid
C A. Incorrect: Altered fetal cerebral blood flow would result in early decelerations in the FHR. B. Incorrect: Umbilical cord compression would result in variable decelerations in the FHR. C. Correct: Uteroplacental insufficiency would result in late decelerations in the FHR. D. Incorrect: Meconium-stained fluid may or may not produce changes in the fetal heart rate, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present. p. 507
The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate may be caused by: a. Narcotics. c. Methamphetamines. b. Barbiturates. d. Tranquilizers.
C Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; methamphetamines may cause increased variability.
The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are the result of: a. Altered cerebral blood flow. c. Uteroplacental insufficiency. b. Umbilical cord compression. d. Meconium fluid.
C Uteroplacental insufficiency would result in late decelerations in the FHR. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Umbilical cord compression would result in variable decelerations in the FHR. Meconium-stained fluid may or may not produce changes in the fetal heart rate, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.
A number of methods to assist in the assessment of fetal well-being have been developed for use in conjunction with electronic fetal monitoring (EFM). These various technologies assist in supporting interventions for a nonreassuring fetal heart rate pattern when necessary. The labor and delivery nurse should be aware that one of these modalities, fetal oxygen saturation monitoring, includes the use of: A. A fetal acoustic stimulator B. Fetal blood sampling C. Fetal pulse oximetry D. Umbilical cord acid-base determination
C Continuous monitoring of the fetal O2 saturation by fetal pulse oximetry is a method that was approved for clinical use in 2000 by the FDA. This process works in a similar method to obtaining a pulse oximetry in a child or adult. A specially designed sensor is inserted into the uterus and lies against the fetus's temple or cheek. A normal result is 30% to 70%, with 30% being the cutoff for further intervention.
The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate might be caused by: A. Narcotics B. Barbiturates C. Methamphetamines D. Tranquilizers
C Narcotics, barbiturates, and tranquilizers might be causes of decreased variability; methamphetamines might cause increased variability.
In assisting with the two factors that have an effect on fetal status pushing and positioning , nurses should:
Encourage the woman's cooperation in avoiding the supine position.
Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by:
Expanding maternal blood volume. [Filling the mother's vascular system makes more blood available to perfuse the placenta and may correct hypotension]
Generally ranging from two to five contractions per 10 minutes of labor
Frequency
Which statement is most likely to be associated with a breech presentation?
High rate of neuromuscular disorders
Which fetal heart rate (FHR) finding would concern the nurse during labor?
Late decelerations [Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected.]
The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. It is likely to be caused by which physiologic alteration?
Late decelerations are almost always caused by uteroplacental insufficiency. [Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption.]
What correctly matches the type of deceleration with its likely cause?
Late deceleration—uteroplacental inefficiency
When using IA for FHR, nurses should be aware that: A. They can be expected to cover only two or three clients when IA is the primary method of fetal assessment. B. The best course is to use the descriptive terms associated with EFM when documenting results. C. If the heartbeat cannot be found immediately, a shift must be made to electronic monitoring. D. Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.
Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if that device is used to help locate the heartbeat. p. 500
Fetal bradycardia is most common during:
Prolonged umbilical cord compression. [Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension.]
Commonly 45 seconds or more in the second stage of labor
Relaxation time
What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken.
Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.
Average of 10 mm Hg
Resting tone
Induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. These include:
Rupture of membranes at or near term. • Chorioamnionitis inflammation of the amniotic sac • Post-term pregnancy. • Fetal death.
After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to:
Stimulate the uterus to contract [Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage.]
The nurse expects to administer an oxytocic, Pitocin, Methergine to a woman after expulsion of her placenta to
Stimulate uterine contraction.
Peaking at 40 to 70 mm Hg in the first stage of labor
Strength
According to standard professional thinking, nurses should auscultate the FHR: A. Every 15 minutes in the active phase of the first stage of labor in the absence of risk factors B. Every 20 minutes in the second stage regardless of whether risk factors are present C. Before and after ambulation and rupture of membranes D. More often in a woman's first pregnancy
The FHR should be auscultated before and after administration of medications and induction of anesthesia.
The nurse recognizes that a woman is in true labor when she states:
The contractions in my uterus are getting stronger and closer together.
What is an advantage of external electronic fetal monitoring?
The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor.
A nurse may be called on to stimulate the fetal scalp:
To elicit an acceleration in the fetal heart rate (FHR). [The scalp can be stimulated using digital pressure during a vaginal examination]
When using intermittent auscultation (IA) for fetal heart rate, nurses should be aware that:
Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.
The nurse providing care for the laboring woman realizes that variable fetal heart rate decelerations are caused by:
Umbilical cord compression. [Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord.]
Which maternal condition is considered a contraindication for the application of internal monitoring devices?
Unruptured membranes [In order to apply internal monitoring devices, the membranes must be ruptured.]
The nurse caring for a woman in labor understands that prolonged decelerations:
Usually are isolated events that end spontaneously.
The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation?
Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency
Why is continuous electronic fetal monitoring usually used when oxytocin is administered?
Uteroplacental exchange may be compromised. [The uterus may contract more firmly, and the resting tone may be increased with oxytocin use]
The nurse caring for the woman in labor should understand that maternal hypotension can result in:
Uteroplacental insufficiency. [Low maternal blood pressure reduces placental blood flow during uterine contractions and results in fetal hypoxemia.]
The nurse providing care for the laboring woman should understand that late fetal heart rate decelerations are the result of:
Uteroplacental insufficiency. [Uteroplacental insufficiency would result in late decelerations in the FHR.]
The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat:
Variable decelerations [Amnioinfusion is used during labor either to dilute meconium-stained amniotic fluid or to supplement the amount of amniotic fluid to reduce the severity of variable decelerations caused by cord compression]
With regards to dysfunctional labor, nurses should be aware that:
Women experiencing precipitous labor are about the only dysfunctionals not to be exhausted
Complications and risks associated with cesarean births include:
Wound dehiscence. Hemorrhage. UTI. Fetal injuries.
The nurse providing care for the laboring woman understands that accelerations with fetal movement: a) Are reassuring b) Are caused by umbilical cord compression c) Warrant close observation d) Are caused by uteroplacental insufficiency
a) Are reassuring
When performing a vaginal examinations on laboring women, the nurse should be guided by what principle?
a) Cleanse the vulva and perineum before and after the examination as needed
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority?
a) Place the woman in the knee-chest position
When using intermittent auscultation to assess uterine activity, nurses should be aware that: a) The examiner's hand should be placed over the fundus before, during, and after contractions b) The frequency and duration of contractions are measured in seconds for consistency c) Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together d) The resting tone between contractions is described as either placid or turbulent
a) The examiner's hand should be placed over the fundus before, during, and after contractions
When assessing a multiparous woman who has just given birth to an 8 pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. The nurse concludes that:
a) The placenta has separated
A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to:
a. Ask her to turn to one side.
Immediately after the forceps-assisted birth of an infant, the nurse should:
a. Assess the infant for signs of trauma. -The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma.
In evaluating the effectiveness of oxytocin induction, the nurse would expect:
a. Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be: a. Dilation of the cervix. b.Descent of the fetus. c. Rupture of the amniotic membranes. d. Increase in bloody show.
a. Dilation of the cervix.
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:
a. Encouraging the woman to try various upright positions, including squatting and standing.
Leopold maneuvers would be an inappropriate method of assessment to determine: a. Gender of the fetus. b. Number of fetuses. c. Fetal lie and attitude. d. Degree of the presenting part's descent into the pelvis.
a. Gender of the fetus.
What is an essential part of nursing care for the laboring woman?
a. Helping the woman manage the pain
A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that "true" labor contractions: a. Increase with activity such as ambulation. b. Decrease with activity. c. Are always accompanied by the rupture of the bag of waters. d. Alternate between a regular and an irregular pattern.
a. Increase with activity such as ambulation.
When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for _________________________ has increased. a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension
a. Intrauterine infection
With regard to the process of augmentation of labor, the nurse should be aware that it:
a. Is part of the active management of labor that is instituted when the labor process is unsatisfactory.
The most critical nursing action in caring for the newborn immediately after birth is: a. Keeping the newborn's airway clear. b. Fostering parent-newborn attachment. c. Drying the newborn and wrapping the infant in a blanket. d. Administering eye drops and vitamin K.
a. Keeping the newborn's airway clear
As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn to incorporate these into a mutually agreed on plan of care. Although it is common practice in the United States for the father of the baby to be present at the birth, in many societies this is not the case. When implementing care, the nurse would anticipate that a woman from which country would have the father of the baby in attendance?
a. Mexico
Which patient status is an acceptable indication for serial oxytocin induction of labor?
a. Past 42 weeks' gestation
A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority?
a. Placing the woman in the knee-chest position
Induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. These include (Select all that apply):
a. Rupture of membranes at or near term. c. Chorioamnionitis (inflammation of the amniotic sac). d. Post-term pregnancy. e. Fetal death
A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to:
a. Stimulate fetal surfactant production.
A means of controlling the birth of the fetal head with a vertex presentation is: a. The Ritgen maneuver. c. The lithotomy position. b. Fundal pressure. d. The De Lee apparatus.
a. The Ritgen maneuver.
When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that: a. The placenta has separated. b. A cervical tear occurred during the birth. c. The woman is beginning to hemorrhage. d. Clots have formed in the upper uterine segment.
a. The placenta has separated.
With regard to a woman's intake and output during labor, nurses should be aware that: a. The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated. c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly.
a. The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia.
Before the physician performs an external version, the nurse should expect an order for a:
a. Tocolytic drug. -A tocolytic drug will relax the uterus before and during version, thus making manipulation easier.
The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births.
a. Viral
A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of:
b) A fetal heart rate (FHR) of 180 with absence of variability
A group of fetal monitoring experts (National Institute of Child Health and Human Development, 2008) recommends that fetal heart rate (FHR) tracings demonstrate certain characteristics to be described as reassuring or normal (category I). This includes: a) Bradycardia not accompanied by baseline variability b) Early decelerations, either present or absent c) Sinusoidal pattern d) Tachycardia
b) Early decelerations, either present or absent
In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information
b) Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures
Which test is performed to determine if membranes are ruptured?
b) Fern test
A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is:
b) It's normal to be anxious about labor. Let's discuss what makes you afraid
Vaginal examinations should be performed by the nurse under all these circumstances except:
b) When accelerations of the fetal heart rate (FHR) are noted
In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, which information would the nurse include?
b. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative
A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: a. "Don't worry about it. You'll do fine." b. "It's normal to be anxious about labor. Let's discuss what makes you afraid." c. "Labor is scary to think about, but the actual experience isn't." d. "You can have an epidural. You won't feel anything."
b. "It's normal to be anxious about labor. Let's discuss what makes you afraid."
A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she would be able to go home. Which response by the nurse is most accurate?
b. "When we can stabilize your preterm labor and arrange home health visits."
The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of:
b. A fetal heart rate (FHR) of 180 with absence of variability.
A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?
b. Active phase
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?
b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours
b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are:
b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth.
Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as: a. First stage, latent phase. b. First stage, active phase. c. First stage, transition phase. d. Second stage, latent phase.
b. First stage, active phase.
While caring for the patient who requires an induction of labor, the nurse should be cognizant that:
b. Labor sometimes can be induced with balloon catheters or laminaria tents.
For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care?
b. Limiting the number of procedures that invade her body
A maternal indication for the use of vacuum extraction is:
b. Maternal exhaustion. -A mother who is exhausted may be unable to assist with the expulsion of the fetus.
What is an expected characteristic of amniotic fluid? a. Deep yellow color b. Pale, straw color with small white particles c. Acidic result on a Nitrazine test d. Absence of ferning
b. Pale, straw color with small white particles
Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance:
b. Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.
After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to: a. Facilitate maternal-newborn interaction. b. Stimulate the uterus to contract. c. Prevent neonatal hypoglycemia. d. Initiate the lactation cycle.
b. Stimulate the uterus to contract.
The primary difference between the labor of a nullipara and that of a multipara is the:
b. Total duration of labor
The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation (Select all that apply)?
b. Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency d. Uterine tone >20 mm Hg e. Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and pattern
Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. An admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture
b. When accelerations of the fetal heart rate (FHR) are noted
With regard to dysfunctional labor, nurses should be aware that:
b. Women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted.
Complications and risks associated with cesarean births include (Select all that apply):
b. Wound dehiscence. c. Hemorrhage. d. Urinary tract infections. e. Fetal injuries
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: a. Relieve pain. b.Stimulate uterine contraction. c.Prevent infection. d. Facilitate rest and relaxation.
b.Stimulate uterine contraction.
Which description of the pases of the second stage of labor is accurate?
c) Descent phase: significant increase in contractions, Ferguson reflex activated, average duration varies
Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period?
c) Encourage skin-to-skin contact of mother and baby
A nurse providing care to a woman in labor should be aware that cesarean birth:
c) Is performed primarily for the benefit of the fetus
With regard to the use of tocolytic therapy to suppress uterine actvity, nurses should be aware that:
c) Its most important function is to afford the opportunity to administer antenatal glucocorticoids
A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: a) Narcotics b) Barbiturates c) Methamphetamines d) Tranquilizers
c) Methamphetamines
A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates her understanding of the instructions when the woman states:
c) True labor contractions will continue and get stronger even if I relax and take a shower
To provide safe care for the woman, the nurse understands that which condition is a contraindication for an amniotomy?
c. -2 station
At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant?
c. 9
A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description?
c. Arrest of active phase
Which description of the phases of the second stage of labor is accurate? a. Latent phase: Feeling sleepy, fetal station 2+ to 4+, duration 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration 5 to 15 minutes c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied d. Transitional phase: Woman "laboring down," fetal station 0, duration 15 minutes
c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied
The least common cause of long, difficult, or abnormal labor (dystocia) is:
c. Disproportion of the pelvis.
Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips. b. Determine the frequency by timing from the end of one contraction to the end of the next contraction. c. Evaluate the intensity by pressing the fingertips into the uterine fundus. d. Assess uterine contractions every 30 minutes throughout the first stage of labor.
c. Evaluate the intensity by pressing the fingertips into the uterine fundus.
A nulliparous woman who has just begun the second stage of her labor would most likely: a. Experience a strong urge to bear down. b. Show perineal bulging. c. Feel tired yet relieved that the worst is over. d. Show an increase in bright red bloody show.
c. Feel tired yet relieved that the worst is over.
Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is: a. Usually directly over the fetal abdomen. b. In a vertex position heard above the mother's umbilicus. c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally. d. In a breech position heard below the mother's umbilicus.
c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally.
The nurse providing care to a woman in labor should understand that cesarean birth:
c. Is performed primarily for the benefit of the fetus. - The most common indications for cesarean birth are danger to the fetus related to labor and birth complications.
As relates to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:
c. Its most important function is to afford the opportunity to administer antenatal glucocorticoids.
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
c. Monitoring uterine response. -Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse's priority intervention is monitoring uterine response.
In planning for home care of a woman with preterm labor, which concern must the nurse address?
c. Prolonged bed rest may cause negative physiologic effects.
Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to:
c. Ripen the cervix in preparation for labor induction.
A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor?
c. She is exhibiting hypertonic uterine dysfunction
It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care?
c. The patient's weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth.
Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?
c. The vulva bulges and encircles the fetal head.
The nurse knows that the second stage of labor, the descent phase, has begun when: a. The amniotic membranes rupture. b. The cervix cannot be felt during a vaginal examination. c. The woman experiences a strong urge to bear down. d. The presenting part is below the ischial spines.
c. The woman experiences a strong urge to bear down.
Surgical, medical, or mechanical methods may be used for labor induction. Which technique is considered a mechanical method of induction?
c. Transcervical catheter - Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of induction.
In documenting labor experiences, nurses should know that a uterine contraction is described according to all of these characteristics except: a) Frequency (how often contractions occur) b) Intensity (the strength of the contraction at its peak) c) Resting tone (The tension in the uterine muscle) d) Appearance (shape and height)
d) Appearance (shape and height)
The most common cause of decreased variability in the FHR that lasts 30 minutes or less is: a) Altered cerebral blood flow b) Fetal hypoxemia c) Umbilical cord compression d) Fetal sleep cycles
d) Fetal sleep cycles
If a woman complains of back labor pain, the nurse might best suggest that she:
d) Lean over a birth ball with her knees on the floor
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? a) Call for help b) Insert a foley catheter c) Start oxytocin (Pitocin) d) Notify the primary health care provider immediately
d) Notify the primary health care provider immediately
For a woman at 42 weeks of gestation, which finding requires more assessment by the nruse?
d) One fetal movement noted in 1 hour of assessment by the mother
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates the preterm labor is occurring
d) The cervix is effacing and dilated to 2 cm
For the labor nurse, care of the expectant mother begins with any or all of these situations except:
d) formulation of the woman's plan of care for labor
In a variation of rooming-in, called couplet care, the mother and infant share a room and the mother shares the care of the infant with:
d) the nurse
In documenting labor experiences, nurses should know that a uterine contraction is described according to all these characteristics except: a. Frequency (how often contractions occur). b. Intensity (the strength of the contraction at its peak). c. Resting tone (the tension in the uterine muscle). d. Appearance (shape and height).
d. Appearance (shape and height).
If a woman complains of back labor pain, the nurse could best suggest that she: a. Lie on her back for a while with her knees bent. b. Do less walking around. c. Take some deep, cleansing breaths. d. Lean over a birth ball with her knees on the floor.
d. Lean over a birth ball with her knees on the floor.
Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)? a. A dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. A reddish-haired mother of two who is going through a breech birth c. A dark-skinned, first-time mother who is going through a long labor d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician
d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician
The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is:
d. A gravida 4 who has had all cesarean births. -The risk of uterine rupture increases for the patient who has had multiple prior births with no vaginal births.
When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should: a. Tell the woman to stay home until her membranes rupture. b. Emphasize that food and fluid intake should stop. c. Arrange for the woman to come to the hospital for labor evaluation. d. Ask the woman to describe why she believes she is in labor.
d. Ask the woman to describe why she believes she is in labor.
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: a. Prepare the woman for imminent birth. b. Notify the woman's primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate and pattern.
d. Assess the fetal heart rate and pattern.
The priority nursing intervention after an amniotomy should be to:
d. Assess the fetal heart rate. -The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred.
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be:
d. Discharged home to await the onset of true labor.
The nurse who performs vaginal examinations to assess a woman's progress in labor should: a. Perform an examination at least once every hour during the active phase of labor. b. Perform the examination with the woman in the supine position. c. Wear two clean gloves for each examination. d. Discuss the findings with the woman and her partner
d. Discuss the findings with the woman and her partner.
For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of: a. The onset of progressive, regular contractions. b. The bloody, or pink, show. c. The spontaneous rupture of membranes. d. Formulation of the woman's plan of care for labor.
d. Formulation of the woman's plan of care for labor.
The nurse thoroughly dries the infant immediately after birth primarily to:
d. Increase blood supply to the hands and feet.
Nurses should be aware that the induction of labor:
d. Is rated for viability by a Bishop score.
For a woman at 42 weeks of gestation, which finding would require further assessment by the nurse?
d. One fetal movement noted in 1 hour of assessment by the mother
Which assessment is least likely to be associated with a breech presentation?
d. Post-term gestation
The standard of care for obstetrics dictates that an internal version may be used to manipulate the:
d. Second twin from a transverse lie to a breech presentation during vaginal birth. -Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally.
In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects?
d. Serum magnesium level of 10 mg/dL
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring?
d. The cervix is effacing and dilated to 2 cm.
With regard to the care management of preterm labor, nurses should be aware that:
d. The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change
External fetal monitoring cannot detect the ____________________ of uterine contractions.
intensity p. 500
When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that:
the woman's risk for intrauterine infection has increased. [When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis.]
A new client and her partner arrive on the labor, delivery, recovery, and postpartum unit for the birth of their first child. You apply the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby's heart rate should be. Your best response is:
"The top line graphs the baby's heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor."
Concerning the third stage of labor, nurses should be aware that: a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate
. b. An expectant or active approach to managing this stage of labor reduces the risk of complications.
Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when: a. The woman has a sudden episode of vomiting. b. The nurse is unable to feel the cervix during a vaginal examination. c. Bloody show increases. d. The woman involuntarily bears down
. b. The nurse is unable to feel the cervix during a vaginal examination.
Normal uterine activity pattern in labor is characterized by:
Contractions every 2 to 5 minutes. [Contractions normally occur every 2 to 5 minutes and last less than 90 seconds with about 30 seconds in between.]
Which collection of risk factors most likely would result in damaging lacerations including episiotomies
A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: a. Change the woman's position. c. Assist with amnioinfusion. b. Notify the care provider. d. Insert a scalp electrode.
A Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, the nurse would continue with subsequent intrauterine resuscitation measures, including notifying the care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely reveals variable deceleration. A fetal scalp electrode would provide accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurse's first priority.
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: a. Change in position. c. Regional anesthesia. b. Oxytocin administration. d. Intravenous analgesic.
A Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration, regional anesthesia, and intravenous analgesic may reduce maternal cardiac output.
When using intermittent auscultation (IA) to assess uterine activity, the nurse should be cognizant that: a. The examiner's hand should be placed over the fundus before, during, and after contractions. b. The frequency and duration of contractions is measured in seconds for consistency. c. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. d. The resting tone between contractions is described as either placid or turbulent.
A The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.
The nurse knows that proper placement of the tocotransducer for electronic fetal monitoring is located: a. Over the uterine fundus. c. Inside the uterus. b. On the fetal scalp. d. Over the mother's lower abdomen.
A The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use.
In assisting with the two factors that have an effect on fetal status (i.e., pushing and positioning), nurses should: a. Encourage the woman's cooperation in avoiding the supine position. b. Advise the woman to avoid the semi-Fowler position. c. Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response. d. Instruct the woman to open her mouth and close her glottis, letting air escape after the push.
A The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. The Valsalva maneuver, which encourages the woman to hold her breath and tighten her abdominal muscles, should be avoided. Both the mouth and glottis should be open, letting air escape during the push.
Fetal tachycardia is most common during: A. Maternal fever B. Umbilical cord prolapse C. Regional anesthesia D. MgSO4 administration
A Correct: Fetal tachycardia can be considered an early sign of fetal hypoxemia and can also result from maternal or fetal infection.
The nurse caring for the woman in labor should understand that decreased variability of the fetal heart rate would be considered benign if caused by: A. A periodic fetal sleep state B. Uterine palpation C. Uterine contractions D. Maternal activity
A Periodic fetal sleep states usually last 20 to 30 minutes.
When using IA to assess uterine activity, nurses should be aware that: A. The examiner's hand should be placed over the fundus before, during, and after contractions. B. The frequency and duration of contractions is measured in seconds for consistency. C. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. D. The resting tone between contractions is described as either placid or turbulent.
A The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed.
In assisting with the two factors that have an effect on fetal status, namely pushing and positioning, nurses should: A. Encourage the woman's cooperation in avoiding the supine position B. Advise the woman to avoid the semi-Fowler position C. Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response D. Instruct the woman to open her mouth and close her glottis, letting air escape after the push
A The woman should maintain a side-lying position.
The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration (Select all that apply)? a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the baby's neck e. Maternal supine hypotension
C, E Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the umbilical cord is around the baby's neck, arm, leg, or other body part or when there is a short cord, a knot in the cord, or a prolapsed cord.
The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman's understanding of the instructions when she states, "True labor contractions will: a. Subside when I walk around." b. Cause discomfort over the top of my uterus." c. Continue and get stronger even if I relax and take a shower." d. Remain irregular but become stronger."
C. Continue and get stronger even if I relax and take a shower."
When assessing the relative advantages and disadvantages of internal and external electronic fetal monitoring, nurses comprehend that both:
Can be used during the antepartum and intrapartum periods.
A tiered system of categorizing FHR has been recommended by regulatory agencies. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. These categories include:
Category I: normal tracing requiring no action Category II: FHR tracings are indeterminate Category III: abnormal; require immediate intervention
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate for five sequential contractions begins to decelerate late in the contraction, with the nadir of the deceleration occurring after the peak of the contraction. The nurse's first priority is to:
Change the woman's position. [Late decelerations may be caused by maternal supine hypotension syndrome.]
Perinatal nurses are legally responsible for:
Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes
Which FHR finding would concern the nurse during labor? A. Accelerations with fetal movement B. Early decelerations C. An average FHR of 126 beats/min D. Late decelerations
D A. Incorrect: Accelerations in the FHR are an indication of fetal well-being. B. Incorrect: Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they generally are not a concern during normal labor. C. Incorrect: This FHR finding is normal and not a concern. D. Correct: Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected. p. 507
The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:
Document the findings because they reflect the expected contraction pattern for the active phase of labor.
Remaining fairly stable throughout the first and second stages
Duration
While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the FHR begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should: A. Change the woman's position B. Discontinue the oxytocin infusion C. Insert an internal monitor D. Document the finding in the client's record
D A. Incorrect: The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings. B. Incorrect: The presence of early decelerations is not an ominous sign and does not require any intervention. C. Incorrect: The presence of early decelerations is not an ominous sign and does not require any intervention. D. Correct: The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings. p. 509
The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: a. Altered cerebral blood flow. c. Umbilical cord compression. b. Fetal hypoxemia. d. Fetal sleep cycles.
D A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Fetal hypoxemia would be evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be seen. Umbilical cord compression would result in variable decelerations in the FHR.
As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations or loss of variability is nonreassuring and is associated with: a. Hypotension. c. Maternal drug use. b. Cord compression. d. Hypoxemia.
D Nonreassuring heart rate patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Fetal variable decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take? a. Scream for help. b. Insert a Foley catheter. c. Start Pitocin. d. Notify the care provider immediately.
D To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. Pitocin may place additional stress on the fetus.
When assessing the relative advantages and disadvantages of internal and external electronic fetal monitoring, nurses should be aware that both: A. Can be used when membranes are intact B. Measure the frequency, duration, and intensity of UCs C. May need to rely on the woman to indicate when UA is occurring D. Can be used during the antepartum and intrapartum periods
D External monitoring can be used in both periods; internal monitoring can be used only in the intrapartum period. p. 500
As a perinatal nurse, you realize that an FHR that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with: A. Hypotension B. Cord compression C. Maternal drug use D. Hypoxemia
D: Nonreassuring heart rate patterns are associated with fetal hypoxemia. pp. 502-503
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly, you see the FHR drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the fetal heart rates remain in the 80s. What additional nursing measures should you take? A. Scream for help B. Insert a Foley catheter C. Start pitocin D. Notify the care provider immediately
D: To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also, if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. p. 511
A nurse might be called on to stimulate the fetal scalp: A. As part of fetal scalp blood sampling B. In response to tocolysis C. In preparation for fetal oxygen saturation monitoring D. To elicit an acceleration in the FHR
DThe scalp can be stimulated using digital pressure during a vaginal examination. p. 513
Nurses should be aware that accelerations in the fetal heart rate: A. Are indications of fetal well-being when they are periodic B. Are greater and longer in preterm gestations C. Are usually seen with breech presentations when they are episodic D. May visibly resemble the shape of the uterine contraction
DThey may resemble the shape of the uterine contraction or may be spikelike. p. 507
While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:
Document the finding in the client's record [The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention]
Which deceleration of the fetal heart rate would not require the nurse to change the maternal position?
Early decelerations [Early decelerations and accelerations generally do not need any nursing intervention.]