Fetal Assessment in Labor(Exam 1)

When applying the ultrasound transducers for continuous external electronic fetal monitoring, the nurse would place the transducer to record the FHR at which location? a) between the umbilicus and the symphysis pubis b) between the xiphoid process and umbilicus c) over the uterine fundus where contractions are most intense d) above the umbilicus toward the right side of the diaphragm

a) between the umbilicus and the symphysis pubis The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

During the active phase of labor, the nurse should evaluate the labor pattern how often? a) every 30 minutes b) every 10 minutes c) every hour d) every 15 minutes

a) every 30 minutes Active labor is a phase when the cervix dilates from 4 to 8 centimeters. The contractions are progressing and occur every 2-5 minutes and last 45-60 seconds. The nurse needs to evaluate the labor pattern every 30 minutes. Longer than 30 minutes may result in missing a transition, and less than 30 minutes may be a waste of time and may cause significant inconveniences to the mother.

When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval? a) every 30 minutes b) every 15 minutes c) every 60 minutes d) every 4 hours

a) every 30 minutes Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first? a) Feel for the fetal back and limbs as the hands move laterally on the abdomen. b) Feel for the fetal buttocks or head while palpating the abdomen. c) Determine flexion by pressing downward toward the symphysis pubis. d) Palpate for the presenting part in the area just above the symphysis pubis.

b) Feel for the fetal buttocks or head while palpating the abdomen. The first maneuver involves feeling for the buttocks and head. Next the nurse palpates on which side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

The expected fetal heart rate response in an active fetus is: a) deceleration followed by acceleration of 15 bpm. b) acceleration of at least 15 bpm for 15 seconds. c) increase in variability by 15 bpm. d) decrease in variability for 15 seconds.

b) acceleration of at least 15 bpm for 15 seconds. A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement.

A client is ready to push. The nurse instructs her to push vigorously by taking a deep breath and pushing hard while counting to 10. The nurse tells her to do three of these maneuvers during the contraction. What would be important to monitor on the client while she is pushing vigorously? a) oxygenation b) heart rate c) perception of her pain d) perineum for lacerations

b) heart rate Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

A client is in the active phase of labor. She is a low-risk client. The nurse evaluates the fetal monitor strip at 10:00 a.m. Moderate variability is present. The FHR is in the 130s with occasional accelerations, no decelerations. At what time does the nurse need to reevaluate the FHR? a) 10:15 a.m. b) 11:15 a.m. c) 10:30 a.m. d) 11:00 a.m.

c) 10:30 a.m. Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns. Variability should be present, except for brief periods of fetal sleep or when the mother receives narcotics or other selected medications, and no late decelerations should be present. Accelerations of the FHR are normal.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which action would the nurse do next? a) Stay with the client while reporting the finding to the primary care provider. b) Administer oxygen after turning the client on her left side. c) Continue to monitor the FHR because this pattern is benign. d) Perform a vaginal exam to assess cervical dilation and effacement.

c) Continue to monitor the FHR because this pattern is benign. Early decelerations are not indicative of fetal distress and do not require intervention. Therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no need to perform a vaginal exam, report the finding to the primary care provider, or administer oxygen.

While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is: a) maternal fatigue. b) maternal hypotension. c) uteroplacental insufficiency. d) cord compression.

c) uteroplacental insufficiency. Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.

The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing intervention? a) Administer oxygen. b) Increase her IV fluids. c) Notify the primary care provider. d) Change the position of the client.

d) Change the position of the client. Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

While monitoring the EFM tracing the nurse notes decelerations with each contraction. The nurse knows that for a deceleration to be classified as early it has to meet three criteria. What is one of these criteria? a) The deceleration ends midway between two contractions. b) The nadir of the deceleration falls midway between the acme of two contractions. c)The FHR begins to accelerate as the contraction begins. d) The nadir of the deceleration coincides with the acme of the contraction.

d) The nadir of the deceleration coincides with the acme of the contraction. Three criteria classify the deceleration as early: (1) the FHR begins to slow as the contraction starts; (2) the lowest point of the deceleration, the nadir, coincides with the acme (highest point) of the contraction; and (3) the deceleration ends by the end of the contraction.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? a) a neonatologist to insert the electrode b) intact membranes c) floating presenting fetal part d) cervical dilation of 2 cm or more

d) cervical dilation of 2 cm or more For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.