Chapter 15: NCLEX practice questions
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? A) Notify nursery nurse of imminent delivery. B) Insert a Foley catheter. C) Start oxytocin (Pitocin). D) Notify the primary health care provider immediately (HCP).
* Notify the primary health care provider immediately (HCP).* Rationale: This is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or non-reassuring pattern, a cesarean section may be warranted. This would require the insertion of a Foley catheter; however, the physician must make that determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately.
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: A) change in position. B) oxytocin administration. C) regional anesthesia. D) intravenous analgesic.
*A) change in position.* Rationale: Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration may reduce maternal cardiac output. Regional anesthesia may reduce maternal cardiac output. Intravenous analgesic may reduce maternal cardiac output.
On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: A) describe the finding in the nurse's notes. B) reposition the woman onto her side. C) call the physician for instructions. D) administer oxygen at 8 to 10 L/min with a tight face mask.
*A) describe the finding in the nurse's notes.* Rationale: *An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix.* These actions would be implemented when non-reassuring or ominous changes are noted. These actions would be implemented when non-reassuring or ominous changes are noted. These actions would be implemented when non-reassuring or ominous changes are noted.
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: A) the examiner's hand should be placed over the fundus before, during, and after contractions. B) the frequency and duration of contractions are measured in seconds for consistency. C) contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. D) the resting tone between contractions is described as either placid or turbulent.
*A) the examiner's hand should be placed over the fundus before, during, and after contractions.* Rationale: The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.
Fetal well-being during labor is assessed by: A) the response of the fetal heart rate (FHR) to uterine contractions (UCs). B) maternal pain control. C) accelerations in the FHR. D) an FHR greater than 110 beats/min.
*A) the response of the fetal heart rate (FHR) to uterine contractions (UCs).* Rationale: Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.
When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: A) maternal hyperthyroidism. B) initiation of epidural anesthesia that resulted in maternal hypotension. C) maternal infection accompanied by fever. D) alteration in maternal position from semirecumbent to lateral.
*B) initiation of epidural anesthesia that resulted in maternal hypotension* Rationale: Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring FHR pattern.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall 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 Pitocin. C) elevate the woman's legs. D) administer oxygen via a tight mask at 8 to 10 L/min.
*B) stop the Pitocin.* Rationale: The woman is already in an appropriate position for uteroplacental perfusion. 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 Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.
A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: A) narcotics. B) barbiturates. C) methamphetamines. D) tranquilizers.
*C) methamphetamines* Rationale: Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates may also result in a significant decrease in variability as these are known to cross the placental barrier. The use of illicit drugs, such as cocaine or methamphetamines, might cause increased variability. Tranquilizer use is a possible cause of decreased variability in the fetal heart rate.
Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? A) FHR does not change as a result of fetal activity. B) Average baseline rate ranges between 100 and 140 beats/min. C) Mild late deceleration patterns occur with some contractions. D) Variability averages between 6 to 10 beats/min.
*D) Variability averages between 6 to 10 beats/min* Rationale: FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system.
Review online quiz for fetal tachycardia and early decelerations
early decelerations: head compression, normal fetal tachycardia: baseline HR >160 NOTE: the interventions for the answers on evolve are wrong (I discussed this with Debbie). Early decelerations should be documented, no intervention required. The interventions listed for early decels DO NOT correspond to fetal tachycardia per Debbie, so it isn't a simple swatch
