Maternal Child Chapter 10
What is a common problem that confronts the client in labor when external fetal monitor has be applied to her abdomen?
Intrusion on movement
At 38 weeks' gestation, a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated at 6 cm, with contractions occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?
Uteroplacental deficiency
During labor, a nurse identifies that there is an early fetal heart rate deceleration. How many fetal heartbeats per minute were there early contractions that indicated to the nurse that deceleration has occurred?
100 to 120
A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?
Auscultating the fetal heart
A nurse is observing a reading on the external fetal monitor of a client in active labor. Which fetal heart pattern indicated cord compression?
Abrupt decreases in fetal heart rate that are unrelated to the contractions
When monitoring the FHR of a client in labor, the nurse identifies an elevation of 15 beats more than the baseline rate of 135 beats/min lasting for 15 seconds. How should the nurse document this event?
An acceleration
After performing Leopold maneuver on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler be placed to best auscultate fetal heart tones?
Below the umbilicus on the right side
A client in active labor has an external fetal monitor in place. Using the monitor strip below, identify the correct assessment.
FHR baseline at 150 beats/min
A external monitor is placed on the abdomen of a client admitted in active labor. The nurse identifies that during each contraction, the fetal heart rate decelerates as the contraction peaks. What should the nurse do next?
Monitor the fetal heart rate until it returns to baseline when the contraction ends
A client in labor begins to experience contractions 2 to 3 minutes apart that last about 45 seconds. Between contractions the nurse identifies a fetal heart rate of 100 beats/min on the internal fetal monitor. What is the next nursing action?
Notify the health care provider
During labor, a client has an internal fetal monitor applied. What fetal heart rate should most concern the nurse?
Returns to baseline heart rate after a contraction ends
An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while this monitor is in place?
The most comfortable position can be assumed
A 36-year-old primigravida, accompanied by her husband, is admitted to the birthing unit at 39 weeks' gestation. External fetal monitoring is instituted. What should the nurse consider when a fetus is being monitored?
The machinery may be frightening to a laboring couple
A client's membranes rupture while laboring is being augmented with an oxytocin infusion. A nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?
Change the client's position
