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The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? Acceleration of at least 15 bpm for 15 seconds Increase in variability by 27 bpm Deceleration followed by acceleration of 15 bpm Decrease in variability for 15 seconds

Correct response: Acceleration of at least 15 bpm for 15 seconds Explanation: A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? Depressed deep tendon reflexes Tachypnea Bradycardia Elevated blood glucose

Correct response: Depressed deep tendon reflexes Explanation: The nurse should assess the woman at least once hourly and report any dyspnea (not tachypnea), tachycardia (not bradycardia), productive cough, adventitious breath sounds, and absent or decreased deep tendon reflexes in a client receiving magnesium sulfate; these are all signs of possible magnesium toxicity. Elevated blood glucose is a potential adverse reaction if the woman is receiving terbutaline.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? Help the woman change positions. Obtain assistance to check for a compressed umbilical cord. Prepare the woman for an emergency cesarean birth. Document the finding.

Correct response: Help the woman change positions. Explanation: First, the nurse should assist the woman to change positions and try to find a position that is comfortable for the woman that relieves the compression. If the variables stop after the position change, the nurse will know that the compression has been relieved. However, if the variables continue, the nurse should try a variety of position changes, including the knee-chest position.

A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time? Push with contractions and rest between them. Hold the breath while pushing during contractions. Begin pushing as soon as the cervix has dilated to 8 cm. Pant while pushing.

Correct response: Push with contractions and rest between them. Explanation: Make sure the woman pushes with contractions and rests between them. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. It is important for women to understand they should not bear down with their abdominal muscles to push until the cervix is fully dilated, which is 10 cm, not 8 cm. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor, such as when a nuchal cord is present.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction.

Correct response: Turn her or ask her to turn to her side. Explanation: The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the fetal heart rate (FHR) with the Doppler at least how often? every 15 to 30 minutes every 30 minutes every hour continuously

Correct response: every hour Explanation: During the latent phase of labor, the nurse should monitor the FHR every 30 to 60 minutes. FHR should be monitored every 30 minutes in the active phase and every 15 to 30 minutes in the transition phase of labor. Continuous monitoring is done when an electronic fetal monitor is used.

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client? hypotonic contractions hypertonic contractions uncoordinated contractions Braxton Hicks contractions

Correct response: hypotonic contractions Explanation: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.