Maternity CH 20
1) The nurse auscultates the F H R and determines a rate of 112 beats/min. Which action is appropriate? A) Inform the maternal client that the rate is normal. B) Reassess the F H R in 5 minutes because the rate is low. C) Report the F H R to the doctor immediately. D) Turn the maternal client on her side and administer oxygen.
Answer: A Explanation: A) A fetal heart rate of 112 beats/min. falls within the normal range of 110-160 beats/min., so there is no need to inform the doctor. B) There is no need to reassess later. C) There is no need to inform the doctor. D) There is no need to reposition the client.
1) The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? A) Woman at 7 c m, fetal heart tones auscultated every 90 minutes B) Woman at 10 c m and pushing, external fetal monitor applied C) Woman with meconium-stained fluid, internal fetal scalp electrode in use D) Woman in preterm labor, external monitor in place
Answer: A Explanation: A) During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough. B) External monitoring can be done instead of auscultation of the fetal heart tones during labor. C) Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present. D) External monitoring during preterm labor will assess both contractions and fetal status.
1) The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus? A) Infection B) Umbilical cord compression C) Vagus nerve stimulation D) Hypoxemia
Answer: A Explanation: A) Infection is one of the most common causes of fetal tachycardia. B) Umbilical cord compression may result in bradycardia, not tachycardia. C) Vagus nerve stimulation may result in bradycardia, not tachycardia. D) Hypoxemia may result in bradycardia, not tachycardia.
1) The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first? A) Perform Leopold maneuvers to determine fetal position. B) Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (U C). C) Dry the maternal abdomen before using the Doppler. D) The diaphragm should be cooled before using the Doppler.
Answer: A Explanation: A) Performing Leopold maneuvers is the first step. B) This is how to auscultate the fetal heart rate, but it is not the first step in assessment. C) Prior to using the Doppler device, a water-based gel is applied to the skin. D) The diaphragm should be warmed before using the Doppler.
1) The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? A) Document the fetal heart rate. B) Apply oxygen via mask at 10 liters. C) Prepare for imminent delivery. D) Assist the client into Fowler's position.
Answer: A Explanation: A) The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. B) No oxygen is necessary. C) There is no indication that delivery will be occurring soon. D) There is no need to put the client in Fowler's position.
1) While caring for a client in labor, the nurse notes the following persistent rhythm on the fetal heart rate monitor: Which action should the nurse take first? A) Notify the provider. B) Prepare for expedient delivery. C) Reposition the client. D) Discontinue oxytocin therapy.
Answer: A Explanation: A) The fetal heart rate monitor demonstrates a persistent sinusoidal pattern. The provider should be notified immediately. B) Expeditious birth of the baby is a priority after the healthcare provider is notified. C) Repositioning the client is not the immediate action that should be taken to address a persistent sinusoidal pattern. D) Discontinuing oxytocin therapy is not the immediate action that should be taken to address a persistent sinusoidal pattern.
1) The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? A) Assist the client to change position. B) Apply oxygen to the client at 2 liters per nasal cannula. C) Notify the operating room of the need for a cesarean birth. D) Determine the color of the leaking amniotic fluid.
Answer: A Explanation: A) The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the woman's upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava. B) A nasal cannula is rarely used in labor and birth. C) There is no indication that a cesarean delivery is needed. D) There is no indication that the amniotic fluid is meconium-stained or bloody.
1) The nurse is assessing the baseline fetal heart rate for a client in labor. What action should the nurse take first? A) Measure the fetal heart rate for 10 minutes B) Round the heart rate to increments of 5 beats/minute C) Exclude periods of marked variation D) Calculate the mean (average) heart rate
Answer: A Explanation: A) The first action the nurse should take is measuring the fetal heart rate for 10 minutes. B) The nurse should round the fetal heart rate to increments of 5 beats/minute after taking a 10-minute measurement of the fetal heart rate. C) The nurse should exclude periods of marked variation after taking a 10-minute measurement of the fetal heart rate. D) The nurse should calculate the mean (average) heart rate after taking a 10-minute measurement of the fetal heart rate.
1) The nurse is reviewing the F H R monitor for a client in labor. The rhythm strip yields the following result: How should the nurse interpret this pattern? A) Moderate variability B) Minimal variability C) Absent variability D) Marked variability
Answer: A Explanation: A) The pattern demonstrates Moderate F H R variability (normal) with an amplitude range of 6 to 25 beats/minute. B) Minimal variability refers to a F H R with an amplitude range detectable but 5 beats/minute or less. C) Absent variability refers to a pattern with no detectable amplitude range. D) Marked variability refers to a pattern with an amplitude range greater than 25 beats/minute.
1) While caring for a client in labor, the nurse notes the following F H R pattern: Which action should the nurse perform? A) Continue to monitor the client B) Fetal scalp stimulation C) Palpate contraction strength D) Discontinue oxytocin
Answer: A Explanation: A) This is a benign finding; there is no slowing of fetal heart rate with contractions. B) Fetal scalp stimulation is not indicated based on this finding. C) Contraction strength assessment is not indicated based on this finding. D) Discontinuing oxytocin should not be performed based on this finding.
1) The nurse is caring for a client who has experienced premature rupture of membranes. For which maternal implication(s) should the nurse monitor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Infection B) Preterm labor C) Dyspnea D) Discomfort E) E) Uterine distention
Answer: A, B Explanation: A) Premature rupture of membranes places the client at an increased risk for infection. B) Premature rupture of membranes places the client at an increased risk for preterm labor. C) Hydramnios, not premature rupture of membranes, increases dyspnea. D) Hydramnios, not premature rupture of membranes, increases discomfort. E) Multiple gestation, not premature rupture of membranes, increases uterine distention.
1) The nurse is caring for a client undergoing fetal heart rate monitoring, and the F H R is greater than 162 beats/min for 12 minutes. For what cause(s) should the nurse anticipate treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Maternal anxiety B) Fetal asphyxia C) Prematurity D) Fetal anemia E) Maternal hypotension
Answer: A, B, C, D Explanation: A) Maternal anxiety may result in fetal tachycardia. B) Fetal asphyxia may result in fetal tachycardia. C) Prematurity may result in fetal tachycardia. D) Fetal anemia may result in fetal tachycardia. E) Maternal hypotension may result in fetal bradycardia, not fetal tachycardia.
1) Upon assessing the F H R tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Early fetal hypoxia B) Prolonged fetal stimulation C) Fetal anemia D) Fetal sleep cycle E) Infection
Answer: A, B, C, E Explanation: A) Early fetal hypoxia can cause fetal tachycardia. B) Prolonged fetal stimulation can cause fetal tachycardia. C) Fetal anemia can cause fetal tachycardia. D) The fetal sleep cycle does not cause fetal tachycardia. E) Infection can cause fetal tachycardia.
1) Fetal factors that possibly indicate electronic fetal monitoring include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Meconium passage B) Multiple gestation C) Preeclampsia D) Grand multiparity E) Decreased fetal movement
Answer: A, B, E Eonxplan: A) Meconium passage is an indicator for electronic fetal monitoring. B) Multiple gestation is an indicator for electronic fetal monitoring. C) Preeclampsia is a maternal indicator for electronic fetal monitoring. D) Grand multiparity is a maternal indicator for electronic fetal monitoring. E) Decreased fetal movement is an indicator for electronic fetal monitoring.
1) Before performing Leopold maneuvers, what would the nurse do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Have the client empty her bladder. B) Place the client in Trendelenburg position. C) Have the client lie on her back with her feet on the bed and knees bent. D) Turn the client to her left side. E) This is not the optimal position for the client when performing Leopold maneuvers.
Answer: A, C Explanation: A) The woman should have recently emptied her bladder before performing Leopold maneuvers. B) Placing the client in Trendelenburg position is not consistent with accurately performing Leopold maneuvers. C) The woman should lie on her back with her abdomen uncovered. To aid in relaxation of the abdominal wall, the shoulders should be raised slightly on a pillow and the knees drawn up a little. D) Placing the client on her left side is not consistent with accurately performing Leopold maneuvers.
1) The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status? A) "How did you decide to have your baby at this hospital?" B) "Who will be your labor support person?" C) "Have you chosen names for your baby yet?" D) "What feeding method will you use for your baby?"
Answer: B Explanation: A) The reason the client is delivering at this facility is not an indication of psychosocial status. B) The expectant mother's partner or support person is an important member of the birthing team, and assessments of the couple's coping, interactions, and teamwork are integral to the nurse's knowledge base. The nurse's physical presence with the laboring woman provides the best opportunity for ongoing assessment. C) Naming the infant is influenced by culture, and is not an indicator of psychosocial status. The chosen feeding method is not an indicator of psychosocial status
1) A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? A) "The most important part of fetal heart monitoring is the absence of variable decelerations." B) "The most important part of fetal heart monitoring is the presence of variability." C) "The most important part of fetal heart monitoring is the fetal heart rate baseline." D) "The most important part of fetal heart monitoring is the depth of decelerations."
Answer: B Explanation: A) Variable decelerations indicate cord compression. B) Baseline variability is a reliable indicator of fetal cardiac and neurologic function, and overall well-being. The opposing "push-pull" balancing between the sympathetic nervous system and the parasympathetic nervous system directly affects the F H R. C) The fetal heart rate baseline does not indicate central nervous system function. D) The depth of decelerations does not indicate central nervous system function.
1) The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? A) "I stimulated the top of the fetus's head to wake him up a little." B) "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." C) "I stimulated the top of the fetus's head to calm the fetus down before birth." D) "I stimulated the top of the fetus's head to find out whether he is in distress."
Answer: B Explanation: A) Waking the fetus is not the goal or outcome of fetal scalp stimulation. B) Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being. C) Calming the fetus is not the goal or outcome of fetal scalp stimulation. D) The nurse wants to assess what the fetus does with stimulation.
1) The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? A) Blood pressure 120/88 B) Father a carrier of sickle-cell trait C) Dark red vaginal bleeding D) History of domestic abuse
Answer: C Explanation: A) Although the diastolic reading is slightly elevated, this blood pressure reading is not the top priority. B) The infant also might have sickle-cell trait, but it is not life-threatening at this time. C) Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus. D) This client is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the client.
1) The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? A) The client is assisted into supine position, and the position of the fetus is assessed. B) The upper portion of the uterus is palpated, then the middle section. C) After determining where the back is located, the cervix is assessed. D) Following voiding, the client's abdomen is palpated from top to bottom.
Answer: C Explanation: A) Determination of fetal position and station is the point of Leopold maneuvers. The client is supine to facilitate uterine palpation. B) This is the correct order of the first and second Leopold maneuvers. C) The cervical exam is not part of Leopold maneuvers. Abdominal palpation is the only technique used for Leopold maneuvers. D) The client is instructed to void prior to beginning Leopold maneuvers to enhance comfort. Leopold maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix.
1) he labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? A) Early decelerations with each contraction B) Variable decelerations that recover to the baseline C) Late decelerations with minimal variability D) Accelerations
Answer: C Explanation: A) Early decelerations are usually benign. B) Variable decelerations indicate cord compression, but those that recover to the baseline indicate that the fetus is tolerating the decelerations. C) Late decelerations are considered a nonreassuring fetal heart rate (F H R) pattern, and therefore require immediate intervention. D) Accelerations of the fetal heart rate indicate good oxygen reserve.
1) Persistent early decelerations are noted. What would the nurse's first action be? A) Turn the mother on her left side and give oxygen. B) Check for prolapsed cord. C) Do nothing. This is a benign pattern. D) Prepare for immediate forceps or cesarean delivery.
Answer: C Explanation: A) Early decelerations do not require any intervention. B) Early decelerations do not indicate a prolapsed cord. C) Early decelerations are considered benign, and do not require any intervention. D) Early decelerations do not warrant an immediate delivery.
1) The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? A) Late decelerations B) Early decelerations C) Accelerations D) Fetal dysrhythmia
Answer: C Explanation: A) Late decelerations indicate uteroplacental insufficiency. B) Early decelerations are indicative of head compression. C) A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the F H R. D) Fetal dysrhythmia is associated with complete heart block in the fetus.
1) The nurse has just palpated contractions and compares the consistency to that of the forehead in order to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? A) Mild B) Moderate C) Strong D) Weak
Answer: C Explanation: A) The consistency of mild contractions is similar to that of the nose. B) The consistency of moderate contractions is similar to that of the chin. C) The consistency of strong contractions is similar to that of the forehead. D) Weak contractions are not identified.
1) The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? A) "The monitor is necessary so we can see how your labor is progressing." B) "The monitor will prevent complications from the meconium in your fluid." C) "The monitor helps us to see how the baby is tolerating labor." D) "The monitor can be removed, and oxygen given instead."
Answer: C Explanation: A) The fetal monitor does not help visualize labor progress. B) The fetal monitor does not prevent complications such as meconium aspiration syndrome. C) Electronic fetal monitoring (E F M) provides a continuous tracing of the fetal heart rate (F H R), allowing characteristics of the F H R to be observed and evaluated. D) Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate.
1) After several hours of labor, the electronic fetal monitor (E F M) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? A) Breech presentation B) Uteroplacental insufficiency C) Compression of the fetal head D) Umbilical cord compression
Answer: D Explanation: A) Breech presentations by themselves do not cause decelerations. B) Uteroplacental insufficiency causes late decelerations. C) Early decelerations occur with fetal head compression. D) Variable decelerations occur when there is umbilical cord compression.
1) A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? A) Change the client's position in bed. B) Notify the physician that birth is imminent. C) Administer oxygen at 2 liters per minute. D) Begin continuous fetal heart rate monitoring.
Answer: D Explanation: A) Changing the client's position is not indicated. B) Meconium-stained amniotic fluid does not indicate that birth is imminent. C) Oxygen administration is not indicated. D) Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring.
1) The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? A) Moderate variability B) Early decelerations C) Late decelerations D) Accelerations
Answer: D Explanation: A) Normal F H R variability is in the moderate range. B) Early deceleration is usually considered benign. C) Late decelerations are caused by uteroplacental insufficiency. The late deceleration pattern is considered a nonreassuring sign. D) Accelerations are thought to be a sign of fetal well-being.
1) After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? A) Increase the mother's oxygen rate. B) Turn the mother to the left lateral position. C) Prepare the mother for a higher-risk delivery. D) Increase the intravenous infusion rate.
Answer: D Explanation: A) Use of oxygen is not a nursing action that would change the status of the depressed fetus. B) Position change to the left side is not a nursing action that would change the status of the depressed fetus. C) Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk. D) Increasing the I V rate is not a nursing action that would change the status of the depressed fetus.