Chapter 15 Fetal Assessment EAQs and Lessons

Which uterine activity would the nurse consider to be reassuring? A. Contraction duration of 60 seconds. B. Contractions occur every 60 seconds. C. Contraction strength is 50 mm Hg during the first D. Contraction duration is 110 seconds. E. Uterine resting tone is 35 mm Hg.

A, C

Which nursing actions are appropriate when the fetal monitor shows a pattern of late decelerations? select all. A. Discontinue oxytocin. B. Provide water to the patient. C. Administer oxygen by face mask. D. Reposition the patient onto her side.

A, C, D

The nurse is assessing a pregnant patient through a tocotransducer placed externally and a spiral electrode placed internally. Which information will the nurse obtain by this arrangement? Select all that apply. One, some, or all responses may be correct. A. Lactate levels in the fetal blood B. Strength of uterine contractions C. Duration of uterine contractions D. Frequency of uterine contractions E. Accelerations of fetal heart rate

C, D, E

Which response would the nurse provide the patient who asks why oxygen is being given after the nurse identifies a nonreassuring fetal heart rate? A. "I will call the health care provider to discuss the new care plan." B. "We need to increase the perfusion of the baby's placenta?" C. "We need to increase your oxygen, which will increase the baby's oxygen." D. "Don't worry. This happens all of the time, and everything is fine."

C. "We need to increase your oxygen, which will increase the baby's oxygen."

Which device is used for monitoring the intensity of uterine contractions (UCs) in a pregnant patient? A. Tocotransducer B. Spiral electrode C. Ultrasound transducer D. Intrauterine pressure catheter (|UPC)

D. Intrauterine pressure catheter (|UPC)

The nurse observes variable decelerations in the fetal heart rate (FHR) while assessing a pregnant patient with oligohydramnios. Which medication should be immediately given to the patient? A. Oxytocin (Pitocin) B. Terbutaline (Brethine) C. Phenylephrine (Endal) D. Lactated Ringer's solution

D. Lactated Ringer's solution

The nurse is evaluating the fetal monitor tracing of a patient who is in active labor. Suddenly, the fetal heart rate (FHR) drops from its baseline of 125 beats/min down to 80 beats/min. The nurse repositions the mother, provides oxygen, increases intravenous (IV) fluid, and performs a vaginal examination. The cervix has not changed. A few minutes have passed, and the FHR remains 80 beats/min. Which additional nursing measures will the nurse take? A. Notify nursery nurse of imminent birth. B. Insert a Foley catheter. C. Start oxytocin (Pitocin). D. Notify the primary health care provider (HCP) immediately.

D. Notify the primary health care provider (HCP) immediately.

Which indicates normal umbilical cord blood values? A. Umbilical artery: pH, 7.1; Pco 2, 50 mm Hg; Po 2, 20 mm Hg B. Umbilical artery: pH, 7.3; Pco 2, 40 mm Hg; Po 2, 10 mm Hg C. Umbilical artery: pH, 7.4; Pco 2, 52 mm Hg; Po 2, 27 mm Hg D. Umbilical artery: pH, 7.3; Pco 2, 45 mm Hg; Po 2, 25 mm Hg

D. Umbilical artery: pH, 7.3; Pco 2, 45 mm Hg; Po 2, 25 mm Hg

Which noninvasive tools may be used to evaluate fetal heart rate? A. Fetoscope B. Uterine palpation C. Doppler ultrasound D. Fetal scalp electrode E. Intrauterine pressure catheter (IUPC)

A, C

After monitoring the fetal heart activity, the nurse concludes that there is impaired fetal oxygenation. Which did the nurse observe in the fetal monitor to come to this conclusion? Select all that apply. One, some, or all responses may be correct. A. Increase in the fetal heart rate (FHR) to over 160 beats/min B. Early decelerations C. Moderate variability D. Late decelerations E. Occasional variable decelerations

A, D

Of these options, which is the nurse's priority action when observing this fetal heart pattern? LATE DECELRATIONS A. Notify the health care provider. B. Assist with vaginal examination to assess for cord prolapse. C. Change maternal position. D. Assist with amnioinfusion.

C. Change maternal position.

Which uterine contraction intensity classification is defined as a firm but not rigid fundus that is difficult to indent with fingertips? A. Mild B. Strong C. Normal D. Moderate

D. Moderate

The nurse is assessing the fetal heart rate (FHR) by using an ultrasound transducer. The patient asks the nurse, "Why are my baby's heart readings not continuous?" Which is the nurse's best response? A. "This is because you may have anxiety." B. "This is a result of fetal movement." C. "Perhaps you have a full bladder." D. "It is because you are lying down now."

B. "This is a result of fetal movement."

The nurse is assessing the fetal heart rate of a woman who is currently lying supine and identifies a nonreassuring pattern. Which recommendation would the nurse make to address this pattern? A. "Elevate your legs." B. "Turn on your side." C. "Walk around the room to reposition the fetus." D. "Remain on your back, and we will reassess in an hour."

B. "Turn on your side."

Which instructions does the nurse give to a patient when preparing to assess the uterine activity using a tocotransducer? A. "No water can be taken until after the test." B. "You will sit up at about a 30-degree angle." C. "Kegel exercises must be done before the test.!" D. "'Remain still while the test is being performed."

B. "You will sit up at about a 30-degree angle."

Which device would the nurse prepare for internal uterine monitoring if the midwife has requested an amnioinfusion? A. A transducer-tip pressure catheter B. An intravenous catheter C. A fluid-filled intrauterine pressure catheter D. A sensor-tip intrauterine pressure catheter

A. A transducer-tip pressure catheter

Match the type of nonreassuring deceleration with the associated cause. 1. Disrupted oxygen transfer 2. Interrupted oxygen supply 3. Umbilical cord compression A. Prolonged B. Late C. Variable

1. B 2. A 3. C

Match the fetal surveillance method to its corresponding advantage. 1. Accurate measurement of fetal heart rate 2. Accurate measurement of uterine contractions, including intensity 3. Noninvasive and suitable for most patients in labor A. External electronic fetal monitoring B. Fetal scalp electrode C. Intrauterine pressure catheter

1. B 2. C 3. A

The nurse understands that _____ Montevideo units (MVUs) is considered adequate for normal labor progression.

200

The nurse is assessing a pregnant patient during labor and reports the normal duration of the contraction period as 2 minutes, 15 seconds in a span of 10 minutes. Which is the number of contractions observed in this span of 10 minutes? Record your answer using a whole number.

3

The nurse is helping a pregnant patient during labor by applying fundal pressure. Which alteration in the fetal heart rate (FHR) pattern may result from this intervention? A. Early decelerations B. Late decelerations C. Variable decelerations D. Prolonged decelerations

A. Early decelerations

Which finding is considered a component of a category II fetal heart rate (FHR) tracing? A. Minimal variability B. Moderate variability C. Less than 110 beats/min D. Presence of accelerations

A. Minimal variability

Which education would the nurse provide a low-risk patient regarding the advantages of intermittent auscultation? A. Allows patient movement B. Allows for a less medical atmosphere C. Appropriate for low-risk patients in labor D. Offers patient more freedom in choosing pain management E. Allows the nurse to assess the fetal heart rate (FHR) during every contraction

A, B, C, D

Which education would the nurse provide a low-risk patient regarding the advantages of intermittent auscultation? Select all that apply. One, some, or all responses may be correct. A. Allows patient movement B. Allows for a less medical atmosphere C. Appropriate for low-risk patients in labor D. Offers patient more freedom in choosing pain management E. Allows the nurse to assess the fetal heart rate (FHR) during every contraction

A, B, C, D

Which are the advantages of external electronic fetal monitoring (EFM)? A. Suitable for most patients in labor B. Visualization of heart rate pattern C. Allows measurement of contraction intensity D. Uninterrupted by fetal or patient movement E. Allows mobility if connected to mobile unit

A, B, E

Fetal monitoring of a pregnant patient reveals a regular smooth, undulating wavelike pattern of the fetal heart rate (FHR). Which will the nurse infer about the fetus from this tracing? A. Anemia B. Ischemia C. Hypertension D. Hypotension

A. Anemia

Which fetal condition can cause a fetal heart rate (FHR) of <60 beats/min for more than 60 seconds that does not quickly return to baseline? A. Cord compression B. Fetal head compression C. Uteroplacental insufficiency D. No compromise; variable decelerations are normal

A. Cord compression

On review of a fetal monitor tracing, the nurse notes that for several contractions the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. Which will the nurse do? A. Describe the finding in the nurse's notes. B. Reposition the woman onto her side. C. Call the physician for instructions. D. Administer oxygen at 8 to 10 L/min with a tight face mask.

A. Describe the finding in the nurse's notes.

The primary health care provider has asked the nurse to draw blood for an umbilical cord acid-base determination test. Which will the nurse do in this situation? A. Administer terbutaline (Brethine) before the test. B. Collect blood from both the umbilical artery and vein. C. First perform the fetal scalp stimulating technique. D. Collect blood only from the baby's umbilical artery.

B. Collect blood from both the umbilical artery and vein.

While auscultating for fetal heart tones in a pregnant patient, the nurse observes that there is persistent fetal tachycardia. In which situation would this finding be considered as normal? A. If the patient's body temperature has increased. B. If the tachycardia is caused by late deceleration. C. If the tachycardia is related to minimal variability. D. If the patient's uterine contractions (UCs) are elevated.

A. If the patient's body temperature has increased.

The primary health care provider has administered terbutaline (Brethine) to a pregnant patient to postpone preterm labor. Which changes will the nurse observe for in the fetal heart monitor after this drug is administered? A. Increase in fetal heart rate B. Decrease in fetal heart rate C. Accelerations in heart rate D. Decelerations in heart rate

A. Increase in fetal heart rate

On assessment, the nurse notices that the fetal heart rate (FHR) is 100 beats/ min. Which is a possible cause for this condition? A. Maternal hypoglycemia B. Chorioamnionitis C. Low fetal oxygen supply D. Decreased fetal hemoglobin levels

A. Maternal hypoglycemia

The nurse is administering an amnioinfusion to a patient with oligohydramnios. Which risk will the nurse monitor for during administration? A. Overdistention of the uterus B. Placental abruption C. Fetal heart rate (FHR) accelerations D. Increased uterine contractions (UCs)

A. Overdistention of the uterus

The nurse caring for an active laboring patient reports to the health care provider that the fetal heart rate (FHR) tracing is reassuring, and the Montevideo units are 60. Which changes in the plan of care will the nurse anticipate from the health care provider? A. Oxytocin augmentation B. Placement of internal monitors C. Artificial rupture of membranes D. No changes in the plan of care

A. Oxytocin augmentation

While assessing a pregnant patient, the nurse observes a sinusoidal heartbeat pattern on the electronic heart monitor. Which will the nurse interpret about the fetus from this report? A. Presence of fetal anemia B. Mild hypoxemia C. Metabolic acidemia D. Potential for congenital anomalies

A. Presence of fetal anemia

The nurse is caring for a woman who is receiving oxytocin. The data displayed on the electronic fetal monitor shows that the contractions are approximately 10 seconds apart. Which intervention would the nurse perform next? A. Stop the oxytocin. B. Call the health care provider. C. Reposition the woman to her side. D. Administer oxygen to the patient.

A. Stop the oxytocin.

The nurse is assessing a pregnant patient and uses spiral electrode monitoring to record the fetal heart rate. Under which circumstances can the nurse consider implementing this method? A. The cervix has partially dilated. B. Uterine contractions have increased. C. The patient's placenta cannot be ruptured. D. The umbilical cord is compressed.

A. The cervix has partially dilated.

When the nurse observes this fetal heart pattern, which nursing action would be the most important? EARLY DECELERATIONS A. To document the finding B. To position mother on left side C. To apply 10 L of oxygen via face mask D. To notify the health care provider

A. To document the finding

In an umbilical cord acid-base report, which value determines placental function? A. Umbilical vein report B. Umbilical artery report C. Amniotic fluid concentration D. Blood glucose concentration

A. Umbilical vein report

The nurse finds that the resting tone of the uterus of a pregnant patient is 30 mm Hg. Under which circumstance is this finding normal? A. When an amnioinfusion is administered to the patient B. When oxytocin (Pitocin) has been given to the patient C. When a blood sample is obtained from the fetal scalp D. When the blood sample is tested for umbilical acid-base

A. When an amnioinfusion is administered to the patient

Which response would the nurse provide to a patient who expresses concern about being switched from intermittent monitoring to continuous electronic monitoring? A. "I need to get more information from your health care provider because your fetus is in distress." B. "This doesn't necessarily mean there's a problem. The health care provider may just want to monitor you more closely." C. "If your partner can leave the room, we can discuss this further." D. "I will let your health care provider know of your concerns."

B. "This doesn't necessarily mean there's a problem. The health care provider may just want to monitor you more closely."

A nurse is caring for a patient in labor who is receiving oxytocin via intravenous infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. A fetal heart rate of 90 beats/min C. A resting uterine tone of 15 mm Hg via the intrauterine pressure catheter D. Early decelerations

B. A fetal heart rate of 90 beats/min

When is fetal heart rate (FHR) and uterine activity (UA) assessment indicated for a low-risk patient in the first stage of labor? A. Every 5 to 15 minutes B. After rupture of membranes C. After administration of oxytocin D. Every 2 hours

B. After rupture of membranes

The nurse assesses the fetal heart rate (FHR) of a pregnant patient and finds minimal FHR variability. The nurse reassesses the patient 30 minutes later and finds moderate variability. Which will the nurse infer? A. No accelerations B. Late decelerations C. Baseline fetal heart rate is 150 beats/min D. Baseline fetal heart rate is 180 beats/min

B. Baseline fetal heart rate is 150 beats/min

Which category of fetal heart rate (FHR) tracing includes tachycardia with minimal variability and periodic variable decelerations? A. Category I B. Category II C. Category III D. Category IV

B. Category II

Which fetal monitoring method is preferred in high-risk preGnancies? A. Intermittent assessment and uterine palpation B. External electronic fetal monitoring (EFM) C. Internal fetal heart rate D. Internal uterine activity

B. External electronic fetal monitoring (EFM)

Which description of moderate variability of the fetal heart rate is accurate? A. Fetal heart rate is 100 beats/min for 15 minutes. B. Fetal heart rate fluctuates between 10 and 20 beats C. Fetal heart rate at baseline has a smooth, flat appearance and fluctuates 2 beats/min. D. Fetal heart rate accelerates 26 beats/min above baseline for a duration of 20 seconds.

B. Fetal heart rate fluctuates between 10 and 20 beats

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110 beats/min. The rate of 110 beats/min persists for more than 10 minutes. The nurse can attribute this decrease in baseline to which factor? A. Maternal hyperthyroidism B. Initiation of epidural anesthesia that resulted in maternal hypotension C. Maternal infection accompanied by fever D. Alteration in maternal position from semi recumbent to lateral

B. Initiation of epidural anesthesia that resulted in maternal hypotension

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of oxytocin (Pitocin). The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. Which is the nurse's immediate action? A. To change the woman's position B. To stop the Pitocin C. To elevate the woman's legs D. To administer oxygen via a tight mask at 8 to 10 L/min

B. To stop the Pitocin

While monitoring the fetal heart rate (FHR), the nurse instructs the patient to change positions and lie in the knee-to-chest position. Which is the reason for the nurse to give this instruction to the patient? A. Late decelerations in the FHR B. Variable decelerations in the FHR C. Early decelerations in the FHR D. Prolonged decelerations in the FHR

B. Variable decelerations in the FHR

A patient is concerned about the baseline variability in the heart rate of her fetus. Which responses by the nurse describe the significance of baseline variability to the patient? A. "Variability is an artifact." B. "Variability is a periodic pattern." C. "Variability demonstrates that there is adequate oxygenation of the fetus." D. "Variability suggests that the fetus is able to adapt to the labor process." E. "Variability indicates that the fetus has no congenital abnormalities."

C, D

Which clinical conditions must be met before placing a fetal scalp monitor? A. Patient should not be in labor B. Absence of fetal scalp hair C. Cervix should be at least 2 cm dilated D. The patient's membranes must be ruptured E. High fetal presentation

C, D

Which uterine activity indicators does the intrauterine pressure catheter (IUPC) measure in mm HG? A. Frequency B. Duration C. Intensity D. Resting tone E. Variability

C, D

The nurse has performed vibroacoustic stimulation and determines that the fetal heart rate (FHR) has increased by 15 beats/min from the baseline for 15 seconds. Which condition does this acceleration indicate? A. Mixed acidemia in the fetus B. Signs of respiratory acidemia C. A normal pH level in the fetus D. Elevated Pco 2 level in the fetus

C. A normal pH level in the fetus

Fetal well-being during labor is assessed by which factor? 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 greater than 110 beats/min

C. Accelerations in the FHR

The nurse is instructed to count the fetal heart rate (FHR for 30 to 60 seconds after each uterine contraction in a pregnant patient via intermittent auscultation. This assessment helps to identify a change in what? A. Placental flow B. Fetal position C. Baseline heart rate D. Uterine activity

C. Baseline heart rate

Which fetal heart rate classification is considered nonreassuring? A. Category I B. Category II C. Category III D. Category IV

C. Category III

Which deceleration is considered a normal finding? A. Variable B. Prolonged C. Early D. Late

C. Early

The nurse caring for the patient in labor understands that absent (or minimal) variability is usually considered nonreassuring. However, which condition related to decreased variability is considered benign? A. Metabolic acidemia B. Central nervous system (CNS) depressant effects C. Fetal sleep D. Local anesthetic agent effects

C. Fetal sleep

Fetal monitoring of a pregnant patient reveals the fetal baseline heart rate is at 170 beats/min. Which maternal condition might the nurse suspect as the cause for this increased fetal heart rate? A. Hypothermia B. Hypoglycemia C. Hyperthermia D. Hypothyroidism

C. Hyperthermia

The nurse notes fetal tachycardia and suspects that the patient may be dehydrated. Which nursing action is appropriate to address this nonreassuring finding? A. Consult with the dietician. B. Administer parenteral feeding. C. Increase the rate of intravenous (IV) saline administration. D. Provide the patient an oral (PO) electrolyte replacement.

C. Increase the rate of intravenous (IV) saline administration.

A patient arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an artificial rupture of membranes (AROM). What will the nurse relay to the patient as the most likely outcome of the procedure? A. Less pressure on the cervix B. Decreased number of contractions C. Increased pressure on the cervix D. The need for more cervical exams

C. Increased pressure on the cervix

The nurse is monitoring a patient in the active stage of labor with internal fetal monitoring. The patient has been experiencing contractions that last 70 to 90 seconds and occur every 1 to 2 minutes, and she has a uterine resting tone of 25 mm Hg. The nurse recognizes that the patient is experiencing which type of difficult labor? A. Hypotonic B. Precipitous C. Tachysystole D. Postterm labor

C. Tachysystole

The nurse instructs a pregnant patient to breathe through the mouth and keep it open while pushing during labor. Which is the rationale for this nursing intervention? A. To avoid nasal congestion in the patient B. To decrease the efforts required for pushing C. To facilitate increased oxygen to the fetus D. To avoid deceleration in the fetal heart rate

C. To facilitate increased oxygen to the fetus

Which fetal heart rate (FHR) change might warrant an amnioinfusion? A. Late decelerations B. Early decelerations C. Variable decelerations D. Prolonged decelerations

C. Variable decelerations

Place the steps in the order in which they would be applied to perform Leopold maneuvers. A. Determine if head is flexed (vertex or extended (face). B. Palpate for the fetal back. C. Palpate the suprapubic area to confirm presentation. D. Palpate the uterine fundus

D, B, C, A

The charge nurse instructed a group of student nurses about the monitoring of uterine activity (UA) during labor. Which statement by the student nurse is accurate regarding the calculation of Montevideo units? A. "They can be calculated using an ultrasound transducer machine." B. "They can be calculated using a spiral electrode monitoring device." C. "They can be calculated using a tocotransducer monitoring system." D. "They can be calculated with an intrauterine pressure catheter (IUPC)."

D. "They can be calculated with an intrauterine pressure catheter (IUPC)."

While assessing a pregnant patient using a fetoscope, the nurse also palpates the abdomen of the patient. Which is the purpose of palpating the abdomen of the patient? A. Detection of fetal heart rate (FHR) deceleration B. Evaluation of the severity of the pain caused by active labor C. Assessment of pain from pressure applied by the fetoscope D. Assessment of changes in FHR during and after contraction

D. Assessment of changes in FHR during and after contraction

Which clinical measure is transmitted by a tocodynamometer? A. Fetal heart rate B. Contraction intensity C. Fetal decelerations D. Contraction frequency

D. Contraction frequency

While performing a vaginal examination of a patient in active labor, the nurse notes decelerations in the fetal heart during uterine contractions (UCs). Which will the nurse do in this situation? A. Stop applying fundal pressure. B. Discontinue the oxytocin (Pitocin) drip. C. Change the maternal position. D. Document it as a normal finding.

D. Document it as a normal finding.

Which fetal heart rate finding may result from maternal fever? A. No expected changes B. Prolonged decelerations C. Fetal heart rate of 90 beats/min for 15 minutes D. Fetal heart rate of 180 beats/min for 12 minutes

D. Fetal heart rate of 180 beats/min for 12 minutes

Which uterine contraction strength classification is used when labor is measured at >500 Montevideo units (MVUs)? A. Normal B. Moderate C. Hypotonic D. Hypertonic

D. Hypertonic

The nurse is caring for a low-risk obstetrical patient in the latent phase of labor. The patient states, "I want to walk around without the fetal monitor on me." How will the labor nurse safely monitor the fetus? A. Periodically obtain a heart rate and variability with a Doppler. B. Periodically auscultate before, during, and between contractions. C. Intermittently place the external fetal monitor to evaluate the fetal heart rate (FHR). D. Intermittently auscultate before, during, and for at least 30 seconds after the contraction.

D. Intermittently auscultate before, during, and for at least 30 seconds after the contraction.

Which umbilical blood gas reading is consistent with respiratory acidosis? A. A base deficit value ≥12 mmol/L B. Blood glucose levels = 120 mg/dL C. Arterial pH >7.20 D. Partial pressure carbon dioxide >55 mm Hg

D. Partial pressure carbon dioxide >55 mm Hg

Which nonreassuring fetal heart rate (FHR) pattern includes a reduction in FHR of 215 beats/min for more than 2 minutes? A. Accelerations B. Tachycardia C. Early decelerations D. Prolonged decelerations

D. Prolonged decelerations

Which maternal or fetal condition might require an amnioinfusion? A. The mother has polyhydramnios (excess amniotic fluid). B. The fetal heart rate (FHR) is 140 beats/min. C. The patient's blood pressure has dropped. D. The fetus has experienced umbilical cord compression.

D. The fetus has experienced umbilical cord compression.

The nurse notes accelerations on the fetal heart rate pattern. Which information is the nurse able to determine given this assessment? A. The fetus has a cord prolapse. B. The patient requires oxygen therapy. C. Immediate nursing intervention is necessary. D. The fetus has normal acid-base balance.

D. The fetus has normal acid-base balance.

After administering phenylephrine (Neo-Synephrine) as prescribed to a pregnant patient, the nurse places the patient in the Trendelenburg position. Which is the rationale for this intervention? A. To reduce the fetal heart rate B. To reduce the effects of tachysystole C. To prevent adverse effects of the drug D. To increase the patient's blood pressure

D. To increase the patient's blood pressure

Which education would the nurse provide a patient who is worried that the intrauterine catheter will hurt the baby? A. "The catheter is placed in the uterus next to the baby." B. "Don't be nervous; everything will be fine!" C. "The catheter attaches only to the outer layer of skin on the baby's head." D. "This is the equipment needed for high-risk pregnancies."

A. "The catheter is placed in the uterus next to the baby."

The nurse is caring for a pregnant patient during labor and documents the strength of uterine contractions (Us) as "mild" after palpating the patient's abdomen. Which reading by the intrauterine pressure catheter (IUPC) is consistent with the strength of the UCs as assessed by the nurse? A. 40 mm Hg B. 60 mm Hg C. 80 mm Hg D. 100 mm Hg

A. 40 mm Hg

The nurse is assisting a pregnant patient in labor. Which instructions will the nurse give to the patient to promote comfort? Select all that apply. One, some, or all responses may be correct. A. "You should cough frequently." B. "Breathe with your mouth open." C. "Lie down in the lateral position. D. "Lie in the supine position in bed." E. "Lie in the semi-Fowler position."

B, C, E

The maternity nurse is monitoring a patient with dysfunctional labor for signs of potential fetal compromise. Which assessment findings would alert the nurse to a potential for fetal compromise? A. Fetal heart rate 115 beats/min B. Absent variability C. No cervical change in 4 hours D. Contractions occurring every 3 minutes and lasting E. Uterine resting tone 30 mm Hg via intrauterine pressure catheter F. Recurrent late decelerations

B, C, E, F

After observing the electronic fetal monitor, a primary health care provider asks the nurse to conduct an electrocardiogram (ECG) of the fetus. Which will the nurse assess before obtaining an ECG of the fetus? Select all that apply. One, some, or all responses may be correct. A. Fetal lactate levels B. Placental membranes C. Cervical dilation D. Umbilical cord compression E. Frequency of uterine contractions

B, C

Which qualities are considered normal when assessing fetal heart rate (FHR)? A. FHR variability of <5 beats/min B. Baseline FHRof 140 beats/min C. FHR variability of 20 beats/min D. Baseline FHR of 100 beats/min E. Baseline FHR of 170 beats/min

B, C

Which characteristics describe early decelerations? A. Most common during second stage of labor B. Referred to as mirror images of contraction C. Primarily periodic and often benign D. Onset, nadir, and recovery correspond with beginning, peak, and end of contraction E. Lowest fetal heart rate usually no lower than 20 beats/min from baseline

B, C, D

Which characteristics describe early decelerations? Select all that apply. One, some, or all responses may be correct. A. Most common during second stage of labor B. Referred to as mirror images of contraction C. Primarily periodic and often benign D. Onset, nadir, and recovery correspond with beginning, peak, and end of contraction E. Lowest fetal heart rate usually no lower than 20 beats/min from baseline

B, C, D

A nurse is beginning to care for a patient in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse makes sure that which implementations occur before initiation of the infusion? A. Placing the patient on complete bed rest B. Continuous electronic fetal monitoring C. An IV infusion of antibiotics D. Making sure that a vial of terbutaline is immediately available E. Preparing an IV infusion pump F. Placing a code cart at the patient's bedside

B, D, E

Which methods are used to assess uterine activity externally? A. Fetal scalp electrode B. Ultrasound transducer C. Palpation D. Intrauterine pressure catheter E. Tocodynamometer

C, E

The nurse knows that patient education has been effective when the patient makes which statement about the difference between a tocodynamometer and an intrauterine pressure catheter (IUPC)? A. "Only the tocodynamometer shows my uterine activity." B. "The tocodynamometer is much more accurate than the IUPC!" C. "The tocodynamometer is positioned outside my body, while the IUPC is positioned inside my body.' D. "The tocodynamometer will be connected to my bedside monitor, but the IUPC will not."

C. "The tocodynamometer is positioned outside my body, while the IUPC is positioned inside my body.'

The nurse is assessing the fetal heart rate (FHR) in a pregnant patient with diabetes during the first stage of labor. At which time intervals should the nurse perform FHR tracing? A. 5 minutes B. 60 minutes C. 15 minutes D. 30 minutes

C. 15 minutes

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? A. FHR does not change with fetal activity. B. Average baseline rate ranges between 100 and 140 beats/min. C. Mild late deceleration patterns occur with some contractions. D. Variability averages between 6 to 10 beats/min.

D. Variability averages between 6 to 10 beats/min.

When does the nurse use the fetal scalp stimulation technique to assess the fetal scalp pH? A. If the patient's contractions have increased B. If there is maternal weight loss in the last trimester C. If fetal bradycardia is present D. When the fetal heart rate (FHR) is within the baseline

D. When the fetal heart rate (FHR) is within the baseline