Exam 4 study questions

The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? 1. Inform the maternal client that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal client on her side and administer oxygen.

Answer: 1 Explanation: 1. A fetal heart rate of 112 beats/min. falls within the normal range of 110-160 beats/min., so there is no need to inform the doctor.

The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters. 3. Prepare for imminent delivery. 4. Assist the client into Fowler's position.

Answer: 1 Explanation: 1. The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary.

The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Assist the client to change position. 2. Apply oxygen to the client at 2 liters per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Determine the color of the leaking amniotic fluid.

Answer: 1 Explanation: 1. The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the woman's upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava.

The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal dehydration 2. Maternal hyperthyroidism 3. Fetal hypoxia 4. Prematurity 5. Anesthesia or regional analgesia

Answer: 1, 2, 3, 4 Explanation: 1. Maternal dehydration can cause fetal tachycardia. 2. Maternal hyperthyroidism can cause fetal tachycardia. 3. Fetal tachycardia can indicate fetal hypoxia. 4. Prematurity can cause fetal tachycardia.

Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Early fetalhypoxia 2. Prolonged fetal stimulation 3. Fetal anemia 4. Fetal sleep cycle 5. Infection

Answer: 1, 2, 3, 5 Explanation: 1. Early fetal hypoxia can cause fetal tachycardia. 2. Prolonged fetal stimulation can cause fetal tachycardia. 3. Fetal anemia can cause fetal tachycardia. 5. Infection can cause fetal tachycardia.

The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal hypotension 2. Prolonged umbilical cord compression 3. Fetal dysrhythmia 4. Central nervous system malformation 5. Late fetal asphyxia

Answer: 1, 2, 3, 5 Explanation: 1. Maternal hypotension results in decreased blood flow to the fetus. 2. Cord compression can cause fetal bradycardia. 3. This will cause fetal bradycardia if there is a fetal heart block. 5. This is a depression of myocardial activity.

The nurse is caring for a client who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal anemia 2. Chronic fetal bleeding 3. Maternal hypotension 4. Twin-to-twin transfusion 5. Umbilical cord occlusion

Answer: 1, 2, 4, 5 Explanation: 1. Fetal anemia can cause a sinusoidal heart rate. 2. Chronic fetal bleeding can cause a sinusoidal heart rate. 4. Twin-to-twin transfusion will cause a sinusoidal heart rate. 5. Umbilical cord occlusion can cause a sinusoidal fetal heart rate.

Fetal factors that possibly indicate electronic fetal monitoring include which of the following? 1. Meconium passage 2. Multiple gestation 3. Preeclampsia 4. Grand multiparity 5. Decreased fetal movement

Answer: 1, 2, 5 Explanation: 1. Meconium passage is an indicator for electronic fetal monitoring. 2. Multiple gestation is an indicator for electronic fetal monitoring. 5. Decreased fetal movement is an indicator for electronic fetal monitoring.

The nurse is caring for a client in the transition phase of labor and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous. 5. Reassure the client and her partner that she is doing fine.

Answer: 1, 5 Explanation: 1. The tracing is normal, so the nurse can continue support of the labor. 5. The nurse can reassure the client at this time, as the tracing is normal.

A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? 1. "The most important part of fetal heart monitoring is the absence of variable decelerations." 2. "The most important part of fetal heart monitoring is the presence of variability." 3. "The most important part of fetal heart monitoring is the fetal heart rate baseline." 4. "The most important part of fetal heart monitoring is the depth of decelerations."

Answer: 2 Explanation: 2. Baseline variability is a reliable indicator of fetal cardiac and neurologic function and well-being. The opposing "push-pull" balancing between the sympathetic nervous system and the parasympathetic nervous system directly affects the FHR.

The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? 1. "I stimulated the top of the fetus's head to wake him up a little." 2. "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." 3. "I stimulated the top of the fetus's head to calm the fetus down before birth." 4. "I stimulated the top of the fetus's head to find out whether he is in distress."

Answer: 2 Explanation: 2. Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being.

The nurse is working with a pregnant adolescent. The client asks the nurse how the baby's condition is determined during labor. The nurse's best response is that during labor, the nurse will do which of the following? 1. Check the client's cervix by doing a pelvic exam every 2 hours. 2. Assess the fetus's heart rate with an electronic fetal monitor. 3. Look at the color and amount of bloody show that the client has. 4. Verify that the client's contractions are strong but not too close together.

Answer: 2 Explanation: 2. This statement best answers the question the client has asked.

A client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check for ruptured membranes and apply a fetal scalp electrode. 2. Auscultate the fetal heart rate between and during contractions. 3. Palpate contractions and resting uterine tone. 4. Assess the blood pressure, temperature, respiratory rate, and pulse rate. 5. Perform a vaginal exam for cervical dilation, and perform Leopold maneuvers.

Answer: 2, 3 Explanation: 2. Fetal heart rate auscultation gives information about the physical status of the fetus. 3. Contraction palpation provides information about the frequency, duration, and intensity of the contractions.

The primary care provider is performing a fetal scalp stimulation test. What result would the nurse hope to observe? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Spontaneous fetal movement 2. Fetal heart acceleration 3. Increase in fetal heart variability 4. Resolution of late decelerations 5. Reactivity associated with the stimulation

Answer: 2, 5 Explanation: 2. The fetal heart rate should accelerate with stimulation. 5. There will be some reaction with the stimulation.

The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? 1. Late decelerations 2. Early decelerations 3. Accelerations 4. Fetal dysrhythmia

Answer: 3 Explanation: 3. A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the FHR.

Persistent early decelerations are noted. What would the nurse's first action be? 1. Turn the mother on her left side and give oxygen. 2. Check for prolapsed cord. 3. Do nothing. This is a benign pattern. 4. Prepare for immediate forceps or cesarean delivery.

Answer: 3 Explanation: 3. Early decelerations are considered benign, and do not require any intervention.

The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? 1. "The monitor is necessary so we can see how your labor is progressing." 2. "The monitor will prevent complications from the meconium in your fluid." 3. "The monitor helps us to see how the baby is tolerating labor." 4. "The monitor can be removed, and oxygen given instead."

Answer: 3 Explanation: 3. Electronic fetal monitoring (EFM) provides a continuous tracing of the fetal heart rate (FHR), allowing characteristics of the FHR to be observed and evaluated.

The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? 1. Moderate variability 2. Early decelerations 3. Late decelerations 4. Accelerations

Answer: 3 Explanation: 3. Late decelerations are caused by uteroplacental insufficiency. The late deceleration pattern is considered a nonreassuring sign.

The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? 1. Early decelerations with each contraction 2. Variable decelerations that recover to the baseline 3. Late decelerations with minimal variability 4. Accelerations

Answer: 3 Explanation: 3. Late decelerations are considered a nonreassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention.

After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? 1. Increase the mother's oxygen rate. 2. Turn the mother to the left lateral position. 3. Prepare the mother for a higher-risk delivery. 4. Increase the intravenous infusion rate.

Answer: 3 Explanation: 3. Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk.

A laboring client asks the nurse, "Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor?" The nurse would accurately explain that the best rationale for using an IUPC is which of the following? 1. The IUPC can be used throughout the birth process. 2. A tocodynamometer is invasive. 3. The IUPC provides more accurate data than does the tocodynamometer. 4. The tocodynamometer can be used only after the cervix is dilated 2 cm.

Answer: 3 Explanation: 3. The IUPC has several benefits over an external tocotransducer or palpation. Because the IUPC is inserted directly into the uterus, it provides near-exact pressure measurements for contraction intensity and uterine resting tone. The increased sensitivity of the IUPC allows for very accurate timing of uterine contractions (UCs).

A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? 1. Change the client's position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring.

Answer: 4 Explanation: 4. Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring.

During a maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in what quadrant? 1. Right upper quadrant 2. Left upper quadrant 3. Right lower quadrant 4. Left lower quadrant

Answer: 4 Explanation: 4. The fetal heart rate (FHR) is heard most clearly at the fetal back. Thus, in a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen.

After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? 1. Breech presentation 2. Uteroplacental insufficiency 3. Compression of the fetal head 4. Umbilical cord compression

Answer: 4 Explanation: 4. Variable decelerations occur when there is umbilical cord compression.