M: Ch 14
45. A nurse documents that the fetal heart rate variability is marked. This indicates that the range is greater than how many beats per minute? Record your answer as a whole number. _____ bpm
ANS: 25 There are four categories of fetal heart rate variability: Absent: Amplitude range is undetectable Minimal: detectable to less than or equal to 5 beats/min Moderate (normal): 6 to 25 beats/min Marked: Range >25 beats/min PTS: 1 DIF: Cognitive Level: Understanding REF: 265 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
Match each term with the correct definition. a. Caused by umbilical cord compression b. Caused by fetal head compression c. Caused by uteroplacental insufficiency 42. Early decelerations 43. Late decelerations 44. Variable decelerations
42.ANS:BPTS:1DIF:Cognitive Level: Understanding REF:264OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity NOT: Fetal head compression briefly increases intracranial pressure, causing the vagus nerve to slow the heart rate. Deficient exchange of oxygen and waste products in the placenta (uteroplacental insufficiency) may result in a pattern of late (delayed) decelerations. Conditions that reduce flow through the umbilical cord may result in variable decelerations. 43.ANS:CPTS:1DIF:Cognitive Level: Understanding REF:265OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity NOT: Fetal head compression briefly increases intracranial pressure, causing the vagus nerve to slow the heart rate. Deficient exchange of oxygen and waste products in the placenta (uteroplacental insufficiency) may result in a pattern of late (delayed) decelerations. Conditions that reduce flow through the umbilical cord may result in variable decelerations. 44.ANS:APTS:1DIF:Cognitive Level: Understanding REF:265OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity NOT: Fetal head compression briefly increases intracranial pressure, causing the vagus nerve to slow the heart rate. Deficient exchange of oxygen and waste products in the placenta (uteroplacental insufficiency) may result in a pattern of late (delayed) decelerations. Conditions that reduce flow through the umbilical cord may result in variable decelerations. SHORT ANSWER
30. Which of the following is the priority intervention for the client in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? a. Administer O2 at 8 to 10 L/min. b. Decrease the IV rate to 100 mL/hr. c. Reposition the ultrasound transducer. d. Perform a vaginal exam to assess for cord prolapse.
ANS: A A deceleration that returns to baseline after the end of the contraction is a late deceleration caused by placental perfusion problems. Administering oxygen will increase the client's blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate, repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord prolapse are not effective interventions to improve fetal oxygenation. PTS: 1 DIF: Cognitive Level: Analysis REF: 267 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance
28. Which client is a candidate for internal monitoring with an intrauterine pressure catheter? a. Obese client whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds b. Gravida 1, para 0, whose contractions are 2 to 3 minutes apart, lasting 60 seconds c. Multigravida whose contractions are 2 minutes apart, lasting 60 to 70 seconds d. Gravida 2, para 1, in latent phase whose contractions are irregular and mild
ANS: A A thick layer of abdominal fat absorbs energy from uterine contractions, reducing their apparent intensity on the monitor strip. Contraction patterns of 2 to 3 minutes lasting 60 seconds and every 2 minutes lasting 60 to 70 seconds indicate accurate measurement of uterine activity. Irregular and mild contractions are common in the latent phase. PTS: 1 DIF: Cognitive Level: Analysis REF: 261 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance
6. Which can be determined only by electronic fetal monitoring? a. Variability b. Tachycardia c. Bradycardia d. Fetal response to contractions
ANS: A Beat-to-beat variability cannot be determined by auscultation because auscultation provides only an average fetal heart rate (FHR) as it fluctuates. Tachycardia can be determined by any of the FHR monitoring techniques. Bradycardia can be determined by any of the FHR monitoring techniques. The fetal response to the contractions is usually noted by an increase or decrease in fetal heart rate. These can be determined by any of the FHR monitoring techniques. PTS: 1 DIF: Cognitive Level: Understanding REF: 263 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity
26. Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should: a. maintain the normal assessment routine. b. administer O2 at 8 to 10 L/min by face mask. c. increase the IV flow rate from 125 to 150 mL/hr. d. assess the maternal blood pressure for a systolic pressure below 100 mm Hg.
ANS: A Decelerations that mirror the contraction are early decelerations caused by fetal head compression. Early decelerations are not associated with fetal compromise and require no intervention. Administering O2, increasing the IV flow rate, and assessing for hypotension are not necessary in early decelerations. PTS: 1 DIF: Cognitive Level: Application REF: 265 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity
3. The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? a. Doppler b. Fetoscope c. Scalp electrode d. Tocodynamometer
ANS: A Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The tocodynamometer does not require gel. This device monitors uterine contractions. PTS: 1 DIF: Cognitive Level: Application REF: 257 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
17. Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by: a. expanding the maternal blood volume. b. maintaining a normal maternal temperature. c. preventing normal maternal hypoglycemia. d. increasing the oxygen-carrying capacity of the maternal blood.
ANS: A Filling the mother's vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not add extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells. PTS: 1 DIF: Cognitive Level: Application REF: 270 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity
33. The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient's contractions. How will the nurse document these findings? a. Late decelerations b. Early decelerations c. Variable decelerations d. Proximal decelerations
ANS: A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contraction's peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal decelerations is not a recognized term. PTS: 1 DIF: Cognitive Level: Understanding REF: 265 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
36. The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? a. Administer oxygen with a face mask at 8 to 10 L/min. b. Reposition the fetal monitor ultrasound transducer. c. Assist the client to the bathroom to empty her bladder . d. Continue to monitor the client and fetal heart rate patterns.
ANS: A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. They reflect possible impaired placental exchange (uteroplacental insufficiency). Administration of 100% oxygen through a snug face mask makes more oxygen available for transfer to the fetus. A commonly suggested rate is 8 to 10 L/min. The pattern is nonreassuring so repositioning the fetal ultrasound transducer, assisting the client to the bathroom, or continuing to monitor the pattern will not correct the problem. PTS: 1 DIF: Cognitive Level: Analysis REF: 267 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity
32. The nurse observes the following data on an electronic fetal monitor attached to a client in the active phase of the first stage of labor: fetal heart rate baseline, 125 to 140 bpm, three accelerations over the course of 20 minutes, moderate variability. What is the priority action based on these findings? a. Document the findings. b. Contact the health care provider. c. Increase the rate of the existing IV to 200 mL/hr as per the standing prescription. d. Place oxygen via a rebreather mask at 10 L/min as per the standing prescription.
ANS: A The findings are all within normal limits for the laboring client. Accelerations are usually a reassuring sign. Normal fetal heart rate is 110 to 160 bpm and of moderate variability; amplitude range of 6 to 25 bpm is desirable. No intervention is required because the pattern suggests that the fetus has adequate reserves to tolerate intrapartum stressors. PTS: 1 DIF: Cognitive Level: Application REF: 263 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
11. In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding? a. The fetus is at 30 weeks of gestation. b. The mother has a history of fast labors. c. The mother has been given an epidural block. d. The mother has mild preeclampsia but is not in labor.
ANS: A The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Fast labors should not alter the FHR normally. Any change in the FHR with an epidural is not considered an expected outcome. Preeclampsia should not cause a normal elevation of the FHR. PTS: 1 DIF: Cognitive Level: Understanding REF: 263 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
34. A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action? a. Stop the infusion of Pitocin. b. Reposition the patient from her right to her left side. c. Perform a vaginal exam to assess for a prolapsed cord. d. Prepare the patient for an emergency cesarean section.
ANS: A There are multiple reasons for late decelerations. Address the probable cause first, such as uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations. Repositioning can increase oxygenation to the fetus but does not address the cause of the problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of moderate variability, the fetus continues to have adequate oxygen reserves. The presence of two or more nonreassuring fetal heart rate patterns increases the level of concern. PTS: 1 DIF: Cognitive Level: Analysis REF: 265 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance
2. Which maternal condition should be considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix dilated to 4 cm c. Fetus has known heart defect d. External monitors currently being used
ANS: A To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm would permit the insertion of fetal scalp electrodes and an intrauterine catheter. A compromised fetus should be monitored with the most accurate monitoring devices. The external monitor can be discontinued after the internal ones are applied. PTS: 1 DIF: Cognitive Level: Understanding REF: 261 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity
38. Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.) a. Oxytocin (Pitocin) b. Misoprostol (Cytotec) c. Dinoprostone (Cervidil) d. Methylergonovine maleate (Methergine)
ANS: A, B, C, D Oxytocin, misoprostol, and dinoprostone fall under the general category of uterine stimulants. Cytotec and Cervidil are prostaglandins. Methergine is an ergot alkaloid. PTS: 1 DIF: Cognitive Level: Application REF: 255 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
39. When evaluating the client's progress, the nurse knows that four of the five fetal factors that interact to regulate the heart rate are (select all that apply): a. baroreceptors. b. adrenal glands. c. chemoreceptors. d. uterine activity. e. autonomic nervous system.
ANS: A, B, C, E The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, whereas parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing accelerations in FHR. Hypertonic uterine activity can reduce the time available for the exchange of oxygen and waste products; however, this is a maternal factor. The fifth fetal factor is the central nervous system. The fetal cerebral cortex causes the heart rate to increase during fetal movement and decrease when the fetus sleeps. PTS: 1 DIF: Cognitive Level: Analysis REF: 254 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity
41. The nurse is preparing supplies for an amnioinfusion on a client with intact membranes. Which supplies should the nurse gather? (Select all that apply.) a. Extra underpads b. Solution of 3% normal saline c. Amniotic hook to perform an amniotomy d. Solid intrauterine pressure catheter with a pressure transducer on its tip
ANS: A, C Amnioinfusion is performed with lactated Ringer's solution or normal saline, not 3%. Normal saline is infused into the uterus through an intrauterine pressure catheter (IUPC). The underpads must be changed regularly because fluid leaks out constantly. The membranes need to be ruptured before an amnioinfusion can be initiated so an amniotic hook will be needed. The IUPC must have a double lumen to run the infusion through. PTS: 1 DIF: Cognitive Level: Application REF: 270 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity MATCHING
4. A client is receiving oxytocin (Pitocin) to induce labor. The uterine contractions have become persistently hypertonic and the infusion is stopped. The health care provider has prescribed a tocolytic to stop contractions. Which medication should the nurse be prepared to administer? a. Naloxone (Narcan) b. Terbutaline (Brethine) c. Ephedrine d. Diphenhydramine (Benadryl)
ANS: B A tocolytic drug, such as terbutaline (0.125 to 0.25 mg IV or 0.25 mg subcutaneously), may be given to reduce uterine activity. Narcan is a narcotic antagonist. Benadryl is an antihistamine. Ephedrine is a vasopressor used to increase blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: 270 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity
24. The physician has ordered an amnioinfusion for the laboring client. What data supports the use of this therapeutic procedure? a. Presenting part not engaged b. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) c. Breech position of fetus d. Twin gestation
ANS: B Amnioinfusion is a procedure used during labor when cord compression or the detection of gross meconium staining is found in the amniotic fluid. A saline solution is used as an irrigation method through the IUPC (intrauterine pressure catheter). PTS: 1 DIF: Cognitive Level: Analysis REF: 274 OBJ:Nursing Process Step: Diagnosis MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation
7. Which is the most appropriate method of intrapartum fetal monitoring when a woman has a history of hypertension during pregnancy? a. Continuous auscultation with a fetoscope b. Continuous electronic fetal monitoring c. Intermittent assessment with a Doppler transducer d. Intermittent electronic fetal monitoring for 15 minutes each hour
ANS: B Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition. It is not practical to provide continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is at high risk for complications. PTS: 1 DIF: Cognitive Level: Application REF: 254 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity
19. Which statement correctly describes the nurse's responsibility related to electronic monitoring? a. Report abnormal findings to the physician before initiating corrective actions. b. Teach the woman and her support person about the monitoring equipment and discuss any of their questions. c. Document the frequency, duration, and intensity of contractions measured by the external device. d. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place.
ANS: B Teaching is an essential part of the nurse's role. Corrective actions should be initiated first to correct abnormal findings as quickly as possible. Electronic monitoring will record the contractions and FHR response. The support person should still be encouraged to assist with the comfort measures. PTS: 1 DIF: Cognitive Level: Application REF: 270 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
18. Which nursing action is correct when initiating electronic fetal monitoring? a. Lubricate the tocotransducer with an ultrasound gel. b. Securely apply the tocotransducer with a strap or belt. c. Inform the client that she should remain in the semi-Fowler position. d. Determine the position of the fetus before attaching the electrode to the maternal abdomen.
ANS: B The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately. The tocotransducer does not need gel to operate appropriately. The client should be encouraged to move around during labor. The tocotransducer should be placed at the fundal area of the uterus. PTS: 1 DIF: Cognitive Level: Application REF: 260 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
22. What is the most likely cause for this fetal heart rate pattern? a. Administration of an epidural for pain relief during labor b. Cord compression c. Breech position of fetus d. Administration of meperidine (Demerol) for pain relief during labor
ANS: B Variable deceleration patterns are seen in response to head compression or cord compression. A breech presentation would not be likely to cause this fetal heart rate pattern. Similarly, administration of medication and/or an epidural would not cause this fetal heart rate pattern. PTS: 1 DIF: Cognitive Level: Analysis REF: 265 OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation
13. When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? a. Early decelerations b. Variable decelerations c. Nonperiodic accelerations d. Increase in baseline variability
ANS: B When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. Early declarations are considered reassuring; they are not a concern after rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Increase in baseline variability is not an expected occurrence after the rupture of membranes. PTS: 1 DIF: Cognitive Level: Analysis REF: 265 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity
40. The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.) a. Post-term fetus b. Maternal fever c. Placenta previa d. Induction of labor e. Prolonged rupture of membranes
ANS: B, C, E Fetal scalp stimulation is not done when there is maternal fever (possibility of introducing microorganisms into the uterus), placenta previa (placenta overlies the cervix, and hemorrhage is likely), or prolonged rupture of membranes (risk of infection). Fetal scalp stimulation may be used to evaluate a post-term fetus' response to stimulation. It is also used to evaluate a fetus when labor is being induced. PTS: 1 DIF: Cognitive Level: Analysis REF: 269 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity
25. Which of the following is the priority intervention for a supine client whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? a. Increase IV infusion. b. Elevate lower extremities. c. Reposition to left side-lying position. d. Administer oxygen per face mask at 4 to 6 L/min.
ANS: C Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the client is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the client is in a supine position. PTS: 1 DIF: Cognitive Level: Application REF: 267 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity
35. The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor? a. Every 10 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes
ANS: C Evaluate the fetal monitoring strip systematically for the elements noted. The following are recommended assessment and documentation intervals for IA and EFM (although facility policies may be different): low-risk women, every 30 minutes during the active phase and every 15 minutes during the second stage. PTS: 1 DIF: Cognitive Level: Understanding REF: 272 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
27. To clarify the fetal condition when baseline variability is absent, the nurse should first: a. monitor fetal oxygen saturation using fetal pulse oximetry. b. notify the physician so that a fetal scalp blood sample can be obtained. c. apply pressure to the fetal scalp with a glove finger using a circular motion. d. increase the rate of nonadditive IV fluid to expand the mother's blood volume.
ANS: C Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An acceleration in response to the massage suggests that the fetus is in normal oxygen and acid-base balance. Monitoring fetal oxygen saturation using fetal pulse oximetry is no longer available in the United States. Obtaining a fetal scalp blood sample is invasive and the results are not immediately available. Increasing the rate of nonadditive IV fluid would not clarify the fetal condition. PTS: 1 DIF: Cognitive Level: Application REF: 269 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
21. Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength? a. External fetal monitoring (EFM) b. Internal fetal monitoring c. Intrauterine pressure catheter (IUPC) d. Maternal comments based on perception
ANS: C IUPC is a clinical tool that provides an accurate assessment of uterine contraction strength. EFM provides evidence of contraction pattern and fetal heart rate but only estimates uterine contraction strength. Internal fetal monitoring provides direct evidence of fetal heart rate and contraction pattern. It only estimates uterine contraction strength. Maternal comments related to pain may not be related to uterine contraction strength and thus are influenced by the client's own pain perception. PTS: 1 DIF: Cognitive Level: Analysis REF: 262 OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation
10. If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen? a. Right upper b. Left upper c. Right lower d. Left lower
ANS: C If the fetus is in a right occiput anterior position, the fetal spine will be on the mother's right side. The best location to hear the fetal heart rate is through the fetal shoulder, which would be in the right lower quadrant. The right upper, left upper, and left lower areas are not the best locations for assessing the fetal heart rate in this case. PTS: 1 DIF: Cognitive Level: Application REF: 260 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
23. Client is at 38 weeks' gestation, gravida 1, para 0, vaginal exam—4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern? a. Continue oxytocin (Pitocin) infusion. b. Contact the anesthesia department for epidural administration. c. Change maternal position. d. Administer Narcan to client and prepare for immediate vaginal delivery.
ANS: C Late decelerations indicate fetal compromise (uteroplacental insufficiency) and are considered to be a significant event requiring immediate assessment and intervention. Of all the options listed, changing maternal position may increase placental perfusion. In the presence of late decelerations, Pitocin infusion should be stopped. Contacting anesthesia for epidural administration will not solve the existing problem of late decelerations. There are no data to support the administration of Narcan and because client is still in early labor, birth is not imminent. PTS: 1 DIF: Cognitive Level: Analysis REF: 266 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation
16. When a nonreassuring pattern of the fetal heart rate is noted and the client is lying on her left side, which nursing action is indicated? a. Lower the head of the bed. b. Place a wedge under the left hip. c. Change her position to the right side. d. Place the mother in Trendelenburg position.
ANS: C Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta. Lowering the head of the bed would not be the first position change choice. The woman is already on her left side, so a wedge on that side would not be an appropriate choice. Repositioning to the opposite side is the first intervention. If unsuccessful with improving the FHR pattern, further changes in position can be attempted; the Trendelenburg position might be the choice. PTS: 1 DIF: Cognitive Level: Application REF: 275 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity
15. The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing: a. a worsening hypoxia. b. progressive acidosis. c. a reassuring response. d. parasympathetic stimulation.
ANS: C The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic stimulation with a temporary increase in the fetal heart rate (FHR) baseline. An increase in the FHR with stimulation does not indicate hypoxia. An increase in the FHR after stimulation is reassuring and does not indicate acidosis. An increase in the FHR after stimulation is a reassuring pattern and does not indicate problems with the parasympathetic nervous system. PTS: 1 DIF: Cognitive Level: Understanding REF: 269 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
12. When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? a. Reposition the client. b. Apply a fetal scalp electrode. c. Record this reassuring pattern. d. Administer oxygen by nasal cannula.
ANS: C The periodic pattern described is early deceleration that is not associated with fetal compromise and requires no intervention. It is a reassuring pattern. Repositioning the client, applying a fetal scalp electrode, or administering oxygen would be interventions done for nonreassuring patterns. PTS: 1 DIF: Cognitive Level: Application REF: 264 OBJ: Nursing Process Step: Intervention MSC: Client Needs: Physiologic Integrity
5. Proper placement of the tocotransducer for electronic fetal monitoring is: a. inside the uterus. b. on the fetal scalp. c. over the uterine fundus. d. over the mother's lower abdomen.
ANS: C The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use. The tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at the fundus; this is the best placement area. PTS: 1 DIF: Cognitive Level: Understanding REF: 261 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
1. The nurse sees a pattern on the fetal monitor that looks similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? a. This pattern reflects variable decelerations. No interventions are necessary at this time. b. Document this reassuring fetal heart rate pattern but decrease the rate of the intravenous (IV) fluid. c. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. d. This deceleration pattern is associated with uteroplacental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply.
ANS: D A pattern similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction, describes a late deceleration. Oxygen should be given via a snug face mask. Position the client on her left side to increase placental blood flow. Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. This is not a reassuring pattern, so the IV rate should be increased to increase the mother's blood volume. These are late decelerations, not early; therefore, interventions are necessary. PTS: 1 DIF: Cognitive Level: Application REF: 265 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity
9. The nurse is concerned that a client's uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take? a. Reposition the tocotransducer. b. Reposition the Doppler transducer. c. Obtain an order from the health care provider for a spiral electrode. d. Obtain an order from the health care provider for an intrauterine pressure catheter.
ANS: D An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this would not be accurate with an obese client, even with repositioning. A Doppler auscultates the FHR. A scalp electrode (or spiral electrode) measures the fetal heart rate (FHR). PTS: 1 DIF: Cognitive Level: Application REF: 262 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity
29. Which client has the priority need for fetal monitoring? a. Primigravida at 38 weeks with spontaneous ROM b. Multigravida at 40 weeks with history of 10-hour labors c. Multigravida admitted for repeat elective cesarean section d. Primigravida at 39 weeks with meconium-stained amniotic fluid
ANS: D Meconium-stained amniotic fluid indicates a potential risk factor during labor. Primigravida at 38 weeks with spontaneous ROM, multigravida with a history of 10-hour labors, and multigravida admitted for repeat elective cesarean section do not have potential maternal or fetal risk factors. PTS: 1 DIF: Cognitive Level: Analysis REF: 256 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity
20. Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation? a. Inhibition of epinephrine b. Inhibition of norepinephrine c. Stimulation of the vagus nerve d. Sympathetic stimulation
ANS: D Sympathetic nerve innervation would result in an increase in fetal heart rate. The release of epinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. The release of norepinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. Stimulation of the vagus nerve would indicate parasympathetic innervation and result in a decreased heart rate. PTS: 1 DIF: Cognitive Level: Application REF: 254 OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity/Reduction of Risk Potential
14. In which situation would it be appropriate to obtain a fetal scalp blood sample to establish fetal well-being? a. The fetus has developed tachycardia related to maternal fever. b. The mother has vaginal bleeding, and the baseline fetal heart rate is decreasing. c. The fetal heart tracing on a preterm fetus shows decreased baseline variability. d. The fetal heart tracing shows a persistent pattern of late decelerations, with normal baseline variability.
ANS: D The tracing is nonreassuring, and additional assessment is needed regarding the acid-base status of the fetus. Fetal scalp blood sampling is contraindicated with vaginal bleeding, maternal fever, and a preterm fetus. PTS: 1 DIF: Cognitive Level: Understanding REF: 269 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity
8. Why is continuous electronic fetal monitoring generally used when oxytocin is administered? a. Fetal chemoreceptors are stimulated. b. The mother may become hypotensive. c. Maternal fluid volume deficit may occur. d. Uteroplacental exchange may be compromised.
ANS: D The uterus may contract more firmly and the resting tone may be increased with oxytocin use. This response reduces the entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Oxytocin affects the uterine muscles. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk. PTS: 1 DIF: Cognitive Level: Understanding REF: 254 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity
31. When a pattern of variable decelerations occur, the nurse should: a. administer O2 at 8 to 10 L/min. b. place a wedge under the right hip. c. increase the IV fluids to 150 mL/hr. d. position client in a knee-chest position.
ANS: D Variable decelerations are caused by conditions that reduce flow through the umbilical cord. The client should be repositioned when the FHR pattern is associated with cord compression. The knee-chest position uses gravity to shift the fetus out of the pelvis to relieve cord compression. Administering oxygen will not be effective until cord compression is relieved. Increasing the IV fluids and placing a wedge under the right hip are not effective interventions for cord compression. PTS: 1 DIF: Cognitive Level: Application REF: 265 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance
37. The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? a. Decrease the rate of the IV fluids. b. Document the fetal heart rate pattern. c. Explain to the client that the pattern is reassuring. d. Perform a vaginal exam to detect a prolapsed cord.
ANS: D Variable decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. A vaginal examination may identify a prolapsed cord, which may cause variable decelerations, bradycardia, or both as it is compressed. A vaginal examination also evaluates the woman's labor status, which helps the birth attendant decide if labor should continue. This is a nonreassuring pattern so the IV rate should be increased and an intervention needs to be done, not just documentation. PTS: 1 DIF: Cognitive Level: Analysis REF: 273 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity MULTIPLE RESPONSE
