ATI Quiz #3

A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? A. A negative test B. A nonreactive test C. A positive test D. A reactive test

B. A nonreactive test Rationale:An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds.

A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? A. Observe color and consistency of fluid. B. Assess the fetal heart rate pattern. C. Assess the client's temperature. D. Evaluate client for the presence of chills and increased uterine tenderness using palpation.

B. Assess the fetal heart rate pattern. Rationale: Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? A. Monitor the client's temperature. B. Assess the fetal heart rate. C. Assess the odor of the amniotic fluid. D. Provide clean, dry underpads.

B. Assess the fetal heart rate. Rationale: The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes.

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep four side rails up while the client is in bed. B. Check the cervix prior to analgesic administration C. Monitor the fetal heart rate (FHR) every hour. D. Insert an indwelling urinary catheter.

B. Check the cervix prior to analgesic administration Rationale: Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn.

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? A. Apply a fetal scalp electrode. B. Increase the rate of the IV infusion. Rationale: C. Administer oxygen at 10 L/min via a nonrebreather mask. D. Change the client's position.

D. Change the client's position. Rationale: The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? A. Early decelerations B. Accelerations C. Late decelerations D. Variable decelerations

D. Variable decelerations Rationale: Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus.

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.) A. Fetal breathing B. Fetal motion C. Fetal neck translucency D. Amniotic fluid volume E. Fetal gender

A, B, D

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching? A. "I will have to lie on my back during the test." B. "My baby's heart rate will be monitored during the test." C. "I should schedule the test when the baby is usually active." D. "It will take 20 to 30 minutes to complete the test."

A. "I will have to lie on my back during the test." Rationale: The client is placed in a Semi-Fowler's position with one hip slightly elevated to promote uterine perfusion and prevent supine hypotension as a result of the uterus compressing the maternal vena cava.

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? A. Contractions lasting longer than 90 seconds B. Contractions occurring every 3 to 5 min C. Contractions are strong in intensity D. Client reports feeling contractions in lower back

A. Contractions lasting longer than 90 seconds Rationale: A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? A. Decrease the rate of infusion of the maintenance IV solution. B. Discontinue the infusion of the IV oxytocin. C. Increase the rate of infusion of the IV oxytocin. D. Slow the client's rate of breathing.

B. Discontinue the infusion of the IV oxytocin. Rationale: Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect? A. Fetal heart rate 100/min B. Weakened uterine contractions C. Enhanced production of fetal lung surfactant D. Maternal blood glucose 63 mg/dL

B. Weakened uterine contractions Rationale: Terbutaline is a beta2-adrenergic agonist that acts to relax uterine smooth muscles. Terbutaline is used to stop contractions in a client who is experiencing preterm labor

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? (Select all that apply.) A. Rh incompatibility B. Cephalopelvic disproportion C. Anomalies in fetal chromosomes D. Neural tube defects E. Fetal gender

C, D, E

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? A. "This will determine if there is more than one fetus." B. "It is useful for estimating fetal age." C. "It assists in identifying the location of the placenta and fetus." D. "This is a screening tool for spina bifida."

C. "It assists in identifying the location of the placenta and fetus." Rationale: Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.

A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching? A. "The test will be performed if your baby's heart beat is heard." B. "This test will determine if your baby's lungs are mature." C. "This test requires the presence of amniotic fluid." D. "After the test, you will be given Rho immune globulin since you are Rh positive."

C. "This test requires the presence of amniotic fluid." Rationale: Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation.

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? A. Recheck the client's temperature in 4 hr. B. Administer glucocorticoids intramuscularly. C. Assess the odor of the amniotic fluid. D. Prepare the client for emergency cesarean section.

C. Assess the odor of the amniotic fluid. Rationale: Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid.

A nurse receives report on a client who is in labor and is experiencing contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? A. Contractions that last for 60 seconds each with a 4-min rest between contractions B. A contraction that lasts 4 min followed by a period of relaxation C. Contractions that last for 60 seconds each with a 3-min rest between contractions D. Contractions that last 45 seconds each with a 3-min rest between contractions

C. Contractions that last for 60 seconds each with a 3-min rest between contractions

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client? A. Food and fluids should not be consumed the day of the procedure. B. Complete a bowel prep protocol the day before the procedure. C. Empty her bladder immediately prior to the procedure. D. Wash her abdomen with soap and water the morning of the procedure.

C. Empty her bladder immediately prior to the procedure. Rationale: Emptying the bladder before amniocentesis prevents possible puncture of the bladder and displacement of the uterus and fetus.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? A. Maintain the client in the lithotomy position. B. Perform vaginal examinations frequently. C. Remind the client to bear down with each contraction. D. Encourage the client to empty her bladder every 2 hr.

D. Encourage the client to empty her bladder every 2 hr. Rationale: A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? A. Vomiting B. Tachycardia C. Respiratory depression D. Hypotension

D. Hypotension Rationale: Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? A. Have the client stand at the bedside with her arms at her side. B. Administer a 500 mL bolus of 5% dextrose in water prior to induction. C. Inform the client the anesthetic effect will last for approximately 6 hr. D. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction.

D. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. Rationale: The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? A. Elevate the client's legs. B. Monitor vital signs every 5 min. C. Notify the provider. D. Place the client in a lateral position

D. Place the client in a lateral position Rationale: Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? A. Palpate the client's uterus. B. Administer oxygen to the client. C. Increase the client's IV fluid infusion rate. D. Turn the client onto her side.

D. Turn the client onto her side. Rationale: When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to turn the client onto her left side. Late decelerations indicate that the client might have uteroplacental insufficiency, maternal hypotension, uterine tachysystole form oxytocin administration, or several other complicating factors. The client might be exerting pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? A. Place the client in the lateral position. B. Increase the rate of maintenance IV infusion. C. Elevate the client's legs. D. Administer oxygen using a nonrebreather mask.

A. Place the client in the lateral position. Rationale: This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? A. Variable decelerations are due to umbilical cord compression. B. Variable decelerations are caused by uteroplacental insufficiency. C. Variable decelerations are a result of the administration of IV narcotic analgesics. D. Variable decelerations are related to fetal head compression.

A. Variable decelerations are due to umbilical cord compression. Rationale: Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? A. Elevate the client's legs. B. Position the client on her side. C. Administer oxygen via face mask. D. Increase the infusion rate of the IV fluid.

B. Position the client on her side.

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following? A. The client is carrying more than one fetus. B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid. C. An excessive amount of amniotic fluid is present. D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor.

C. An excessive amount of amniotic fluid is present. Rationale: An excess of amniotic fluid is defined as amniotic fluid pockets of >8 cm or an amniotic fluid index of greater than 25. Polyhydramnios or hydramnios is associated with neural tube defects, obstructions of the fetal gastrointestinal tract, multiple fetuses, and fetal hydrops.

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? A. Prepare for a cesarean birth. B. Assist the client to an upright position. C. Prepare for an immediate vaginal delivery. D. Assist the client to turn onto her side.

D. Assist the client to turn onto her side. Rationale: Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? A. Immediately report the situation to the client's provider and prepare the client for induction of labor. B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. C. Offer the client a snack of orange juice and crackers. D. Turn the client onto her left side.

C. Offer the client a snack of orange juice and crackers. Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? A. There is evidence of cervical incompetence. B. There is no evidence of two or more accelerations in fetal heart rate in 20 min. C. There is no evidence of uteroplacental insufficiency. D. There are less than 3 uterine contractions in a 10-min period.

C. There is no evidence of uteroplacental insufficiency. Rationale: A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations.