Maternity MNL 20

The nurse is monitoring a low-risk patient who is in labor. Which action should the nurse take first? A. Insert internal pressure catheter. B. Assess fetal heart tones. C. Prepare patient for telemetry. Apply fetal scalp electrode.

B. Assess fetal heart tones.

The nurse is caring for a patient in labor. For which health problem should the nurse monitor for seizure activity? A. Preeclampsia B. Premature rupture of membranes (PROM) C. Diabetes D. Hydramnios

a. Preeclampsia

A patient in labor is encouraged to walk in the hallway as a distraction technique. Which action should the nurse take before the patient begins ambulation? a. Assess the fetal heart rate. B. Apply no-slip socks to the patient's feet. C. Administer pain medication. D. Encourage the partner to walk with the patient.

a. Assess the fetal heart rate.

A patient's fetal heart rate ranges from 110 to 120 beats/min between contractions. In which way should the nurse interpret this information? A. Variable fetal heart rate B. Fetal tachycardia C. Baseline fetal heart rate D. Fetal bradycardia

C. Baseline fetal heart rate

The nurse is assessing the fetal heart rate in a patient with polyhydramnios. Which outcome should the nurse expect? a. The fetal heartbeat is difficult to hear. b. The fetal heartbeat is absent. c. The fetal heartbeat indicates tachycardia. d. The fetal heartbeat is irregular.

a. The fetal heartbeat is difficult to hear.

The nurse is observing a patient's electronic fetal monitor. Which finding should require immediate intervention? a. Variable decelerations that recover to baseline b. Early decelerations with contractions c. Accelerations d. Late decelerations with minimal variability

d. Late decelerations with minimal variability Late decelerations are considered a nonreassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention. Early decelerations are usually benign. Variable decelerations indicate cord compression, but those that recover to the baseline indicate that the fetus is tolerating the decelerations. Accelerations of the fetal heart rate indicate good oxygen reserve.

The nurse is assessing fetal heart rate in a pregnant patient. Which part of the abdomen should be used if the fetus is in cephalic presentation? a. Upper quadrant b. Below the umbilicus c. Above the umbilicus d. Lower quadrant

d. Lower quadrant When the fetus is in a cephalic presentation, the fetal heart rate (FHR) is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, the FHR is heard at or above the maternal umbilicus. In a transverse lie position, the FHR may be heard best just above or just below the maternal umbilicus. Fetal heart rate is never assessed in the upper maternal abdomen.

The fetus of a patient in labor is experiencing bradycardia. Which situation should the nurse expect to occur if the bradycardia continues? a. Hypertension B. Congenital malformations C. Delayed delivery D. Acidemia

D. Acidemia If bradycardia is not corrected quickly, the fetus can develop acidemia. Bradycardia does not lead to hypertension, delayed delivery, or congenital malformations.

A patient is exhibiting early decelerations on the fetal heart rate monitor. Which action should the nurse take? A. Position the patient on the left side. B. Provide oxygen to the patient. C. Increase intravenous fluids. D. Continue to monitor

D. Continue to monitor Early decelerations are a result of uterine contractions, causing fetal head compression and stimulating the vagus nerve. They are viewed as a reassuring pattern and the patient should be monitored. Because early decelerations are not associated with fetal hypoxia, oxygen and repositioning the patient are not appropriate actions. Since early decelerations are not associated with decreased cardiac output, increasing intravenous fluids is not an appropriate action.

The nurse is caring for a patient in labor. For which fetal position should the patient be placed on the hands and knees? A. Occiput anterior B. Shoulder presentation C. Breech D. Occiput posterior

D. Occiput posterior When the fetus is in the persistent occiput posterior position, side-lying or hands and knees positions can promote fetal head rotation. Occiput anterior fetal position is not aided by a hands and knees position. A fetus in breech or shoulder presentation may need a cesarean birth.

The nurse reviews information received during handoff communication. Which patient should the nurse identify as having the greatest risk for a prolapsed umbilical cord? A. 40 weeks' gestation, 5 cm dilated, 100% effaced, -2 station, ruptured membranes B. 40 weeks' gestation, 5 cm dilated, 100% effaced, -2 station, intact membranes C. 38 weeks' gestation, 3 cm dilated, 80% effaced, 0 station, intact membranes D. 39 weeks' gestation, 9 cm dilated, 100% effaced, +1 station, ruptured membranes

A. 40 weeks' gestation, 5 cm dilated, 100% effaced, -2 station, ruptured membranes Prolapse is more likely to occur in a patient with an abnormal fetal presentation, such as high station. Rupture of amniotic membranes also increases the risk of cord prolapse. The chance of a prolapsed cord is less if the presenting fetal part is engaged.

A patient in labor experiences trickling of amniotic fluid during contractions. Which action should the nurse take? A. Clean up the leaking fluid. B. Decrease the epidural dose. C. Document the patient's pain level. D. Position the patient on the left side.

A. Clean up the leaking fluid.

The nurse is preparing to assess a patient in labor. Which action should the patient complete first in preparation for Leopold maneuvers? A. Empty the bladder. B. Declare when a contraction begins. C. Bend the knees. D. Place a pillow behind the shoulders.

A. Empty the bladder.

The nurse is preparing to assess fetal heart rate with a Doppler. At which maternal location should the nurse place the diaphragm of the device? A. Midline B. Bottom of the symphysis C. Left side of the abdomen D. Top of the umbilicus

A. Midline

The fetus of a patient in the first stage of labor is in the occiput posterior position. In which way should the nurse position the patient? A. On hands and knees B. Standing C. Squatting D. Sitting

A. On hands and knees When the fetus is in the persistent occiput posterior position, side-lying or hands and knees positions can promote fetal head rotation. Standing, squatting, and sitting in an upright position may all be beneficial during labor, but are not the best positions for a patient whose fetus is in the occiput posterior position.

The electronic monitor shows repetitive variable decelerations in the fetal heart rate of a patient in labor. Which health problem should the nurse anticipate? A. Umbilical cord compression B. Breech presentation C. Fetal transverse lie D. Fetal hypoglycemia

A. Umbilical cord compression Fetal variable decelerations occur when there is umbilical cord compression. Breech presentation alone does not cause variable decelerations. Fetal transverse lie and fetal hypoglycemia do not cause variable decelerations.

A patient in the first stage of labor is diagnosed with preeclampsia. Which patient statement should indicate the need for further teaching about fetal heart rate assessment? A. "You're going to put gel on my belly so you can hear the baby's heartbeat clearly." B. "You're going to listen to my baby's heartbeat every 5 minutes." C. "If you can't find the baby's heartbeat, you're going to move the Doppler until you hear it." D."When you listen to my baby's heartbeat, you're going to take my pulse."

B. "You're going to listen to my baby's heartbeat every 5 minutes." Fetal heart rate should be monitored every 15 minutes for a high-risk patient in the first stage of labor. The other patient statements are correct.

The nurse prepares to assess the fetal heart rate of a patient in labor. Which statement should the nurse make to explain the procedure? A. "I'm going to wait until your next contraction ends, and then I'll listen to the heartbeat for 15 seconds." B. "I'm going to listen to the heartbeat until your next contraction starts." C. "I'm going to listen to the heartbeat for a full minute, and I'll need to continue during and after your next contraction." D. "I'm going to listen to the heartbeat for 45 seconds as soon as your next contraction starts."

C. "I'm going to listen to the heartbeat for a full minute, and I'll need to continue during and after your next contraction."

A patient having labor induced is exhibiting hypertonicity systole uterine contractions. Which action should the nurse take? A. Ask the patient to bear down. B. Turn the patient to the right side. C. Stop oxytocin infusion. D. Prepare for imminent delivery.

C. Stop oxytocin infusion.

A patient in labor is having trouble concentrating. Which psychologic disorder should the nurse expect to be documented that validates the patient's behavior? a. Clinical depression b. Psychosis c. Obsessive-compulsive disorder d. Generalized anxiety

a. Clinical depression The patient in labor exhibiting trouble concentrating may have clinical depression. Performing a ritualistic behavior to relieve an irrational impulse is associated with obsessive-compulsive disorder. Continual and excessive worrying is associated with generalized anxiety disorder. Hallucinations and delusions are associated with psychosis.

A patient in labor has painless vaginal bleeding. Which action should the nurse make a priority? a. Administer oxygen by face mask. b. Assess fetal presentation. c. Assess fetal heart rate. d. Place in side-lying position.

c. Assess fetal heart rate. The immediate nursing action for a patient in labor experiencing painless vaginal bleeding is to assess the fetal heart rate. Assessing fetal presentation is an immediate nursing action for a patient with greenish or brownish amniotic fluid. Administering oxygen by face mask and placing the patient in a side-lying position are immediate nursing actions if the fetal heart rate is less than 110 beats per minute.