Ch. 14 - EX - 2
10. 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.
a
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
a
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.
a
1. SATA - 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)
a, b, c, d
2. SATA - 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.
a, b, c, e
4. SATA - 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
a, c
In which of the following situations would fetal oxygenation be compromised? a. The mother has been taking Tylenol for mild headaches 2 days prior to the onset of labor. b. The mother regularly sleeps on her left side. c. The mother routinely uses cocaine. d. The mother drinks one caffeine drink a day.
C Cocaine use produces maternal hypertension. Hypertension in the mother reduces blood flow to the placenta and decreases the fetal oxygenation.
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.
c
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 normal pattern. d. Administer oxygen by nasal cannula.
c
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.
c
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
c
14. When a category II (or nonreassuring) pattern of the fetal heart rate is noted and the patient 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 him. c. Change her position to the right side. d. Place the mother in Trendelenburg postion.
c.
25. 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
a
33. Which clinical finding would be considered normal for a preterm fetus during the labor period? a. Baseline tachycardia b. Baseline bradycardia c. Fetal anemia d. Acidosis
a
5. Which can be determined only by electronic fetal monitoring? a. Variability b. Tachycardia c. Bradycardia d. Fetal response to contractions
a
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.
a
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.
a
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
a
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
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
Mathching: 42. Early decelerations 43. Late decelerations 44. Variable decelerations a. Caused by umbilical cord compression b. Caused by fetal head compression c. Caused by uteroplacental insufficiency
42. B - 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. C - 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. A - 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.
On review of a fetal monitor tracing, the nurse notes that for several contractions the FHR decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: a. Describe the finding in the notes. b. Reposition the woman onto her side. c. Call the physician for instructions. d. Administer oxygen at 8 to10 L/min with a tight face mask.
A An early deceleration pattern from head compression is described. No action other than documentation of the finding is required because this is an expected reaction to compression of the fetal head as it passes through the cervix. The other responses would be implemented when nonreassuring or ominous changes are noted.
During a vaginal exam, the physician stimulates the fetal scalp. The fetal heart rate accelerated from 140 to 155 bpm for about 30 seconds. The nurse should: a. Record this reassuring fetal reaction. b. Notify the physician because this reaction is nonreassuring. c. Assist the woman into a side-lying position. d. Administer oxygen at 8 to 10 L/min.
A It is reassuring for the heart rate to elevate 15 bpm for at least 15 seconds with fetal scalp stimulation. The nurse should record the finding. No other intervention is necessary at this time.
After several mild late decelerations, the physician obtains a fetal scalp blood sample. The fetal pH was 7.32. The nurse is aware that the next action will probably be to: a. Continue to monitor the fetus during the labor. b. Prepare for a cesarean section. c. Prepare for a reassessment of the fetal pH. d. Apply oxygen to the mother at a rate of 10 L/min.
A The normal fetal pH is 7.25 to 7.35. Because this fetal pH is within the normal limits, the nurse can anticipate continuing monitoring of the fetus. Because the pH is within normal limits, it is unlikely that a cesarean section would be performed at this time.
Which of these might cause late decelerations in the fetus? (Select all that apply). a. Maternal hypotension b. Excessive uterine activity c. Maternal hypertension d. Fever e. Maternal overhydration f. Prolapsed cord
A, B, C
Which of the following are considered nonreassuring fetal heart rate patterns? (Select all that apply). a. Tachycardia b. Bradycardia c. Absent variability d. Early decelerations e. Variable decelerations
A, B, C, E
Variability can be reduced by which of the following factors? (Select all that apply). a. Sleep b. Narcotics c. Gestation longer than 39 weeks d. Fetal anomalies that affect the central nervous system
A, B, D
To ensure adequate fetal oxygenation, which of the following are needed? (Select all that apply). a. Normal maternal blood flow and volume to the placenta Correct b. Normal oxygen saturation in maternal blood c. Normal carbon dioxide saturation in the maternal blood d. Adequate exchange of oxygen and carbon dioxide in the placenta e. Normal fetal circulatory and oxygen-carrying functions f. Normal blood glucose levels in the fetal circulation
A, B, D, E
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.
a
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 correcterm-24t 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.
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.
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
a
A primigravida is in the latent phase of labor and is at low risk for complications of labor. She asks the nurse if she may walk for a few minutes. The nurse is aware that this is (is not) possible because: a. Continuous fetal monitoring is required. b. Continuous monitoring of the contractions is necessary at this stage of labor. c. Intermittent auscultation of fetal heart rate is appropriate for her. d. There is no need to assess fetal heart rate at this early stage of labor.
C Continuous fetal and uterine monitoring are not necessary for the latent phase of labor in women who are at low risk for complications.
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.
A fetal pulse oximetry is applied to a fetus. The reading shows an oxygen saturation of 45%. The nurse realizes that this means: a. A low reading; normal should be above 95%. b. A high reading; normal should be between 20% and 30%. c. A normal reading. d. This is not conclusive.
C A normal fetal pulse oximetry reading is 30% to 70%. A normal reading for an adult is between 95% and 100%. The lower reading is considered normal because of the high hemoglobin and hematocrit levels in the fetus compared with those of an adult.
In caring for a low-risk woman in the active phase of labor, the nurse realizes the assessment of fetal well-being should occur: a. Every 15 minutes. b. Every 30 minutes. c. Every 5 minutes. d. Every hour.
B For low-risk women, the nurse should evaluate the fetal monitoring strip or assessment fetal well-being at least every 30 minutes during the active phase of labor and every 15 minutes during the second stage. For the high-risk woman, monitoring should occur every 15 minutes during the active phase and every 5 minutes during the second stage.
The nurse is preparing to auscultate the fetal heart rate using a Doppler transducer. When performing the Leopold maneuver, the nurse felt the buttocks near the fundus and the back along the left side of the mother. The best position for the Doppler would be in the mother's: a. Left upper quadrant. b. Left lower quadrant. c. Right upper quadrant. d. Right lower quadrant.
B The fetal heart is best heard through the fetus's upper back. Because this fetus is in a cephalic position, with the back toward the mother's left side, the Doppler should be placed in the left lower quadrant of the mother's abdomen.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of oxytocin (Pitocin). The woman is in a side-lying position and her vital signs are stable, falling within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's immediate action would be to: a. Change the woman's position. b. Stop the oxytocin. c. Elevate the woman's legs. d. Administer oxygen via a tight mask at 8 to 10 L/min.
B The late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the oxytocin infusion because oxytocin stimulates the uterus to contract. The woman is already in an appropriate position for uteroplacental perfusion. Elevating her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.
Fluctuations in the baseline FHR that cause the printed line to have an irregular rather than a smooth appearance is termed ___________________.
Variability
Firm contractions that occur every 3 minutes and last 100 seconds may reduce fetal oxygen supply because they: a. Cause fetal bradycardia and reduce oxygen concentration. b. Activate the fetal sympathetic nervous system. c. Limit the time for oxygen exchange in the placenta. d. Suppress the normal variability of the fetal heart.
C The resting time between these contractions is about 80 seconds, which reduces the time available for exchange of oxygen and waste products in the placenta. This will reduce the fetal oxygen supply. The other choices can all be results of the decreased oxygen supply.
Which of the following findings meets the criteria of a reassuring FHR pattern? a. The FHR does not change as a result of fetal activity. b. The average baseline rate ranges between 90 and 110 bpm. c. Mild late deceleration patterns occur with some contractions. d. Variability averages between 6 and 25 bpm.
D Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. The FHR should accelerate with fetal movement. Baseline range for the FHR is from 110 to 160 bpm. Late deceleration patterns are never reassuring.
15. 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 patient that she should remain in the semi-Fowler position. d. Determine the position of the fetus before attaching the electrode to the maternal abdomen.
b
17. 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
b
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
b
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
b
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
b
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
b
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.
b
3. SATA - 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
b, c, e
13. 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. an expected response d. parasympathetic stimulation
c
20. The patient presenting 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.
c
30. 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
c
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
c
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.
c
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.
d
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.
d
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.
d
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.
d
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.
d
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.
d
