NCLEX_Ch_21

7. A nurse is auscultating the heart rate of a fetus in a cephalic presentation. Where should the nurse place her stethoscope so that she hears the heart rate most clearly? a. Above the apex of the fetal heart. b. Level with the maternal umbilicus. c. The upper quadrant of the maternal abdomen. d. The lower quadrant of the maternal abdomen.

ANS: D 7. The lower quadrant of the maternal abdomen. Rationale: The lower quadrant of the maternal abdomen is where the nurse should hear the fetal heart rate (FHR) in a cephalic presentation. Hearing the FHR at the level of the maternal umbilicus is expected when the fetus is in a transverse presentation. Hearing the FHR in the upper quadrant of the maternal abdomen is appropriate for a breech presentation. FHR is heard most clearly along the back of the fetus, not at the apex of the fetal heart.

4. The nurse is evaluating an intrapartal client's lab results. Which laboratory finding should the nurse report to the physician or nurse-midwife? a. Platelets: 120,000/mm. b. Hematocrit: 45%. c. Leukocyte count: 19,000/mm. d. White blood count: 11,000/mm.

ANS: A 4. Platelets: 120,000/mm. Rationale: The platelets (120,000/mm) should be reported as abnormally low; also called thrombocytopenia. (Normal: 250,000-500,000/mm) The hematocrit, leukocyte count, and white blood count are within normal limits for a laboring woman.

6. A nurse is planning to perform Leopold's maneuvers on a laboring client. What should the nurse's initial action be? a. Position the client in a supine position. b. Have the client void. c. Apply sterile lubricant to the abdomen. d. Wash hands in warm water.

ANS: B 6. Have the client void. Rationale: Having the client void before performing Leopold's maneuvers provides for improved comfort during the evaluation for the laboring client. Positioning the client on her back is correct, but this is not the initial action. The examiner's hands should be warm, but this is not the initial action. Applying sterile lubricant to the abdomen is not part of the procedure.

2. The physician orders internal monitoring of contractions for a laboring client. What criteria must the client meet prior to this procedure? Select all that apply. a. The fetal part must be engaged. b. The cervix must be dilated. c. The membranes must be ruptured. d. There must be cephalic presentation.

ANS: C, B 2. The membranes must be ruptured. The cervix must be dilated. Rationale: The membranes must be ruptured for internal fetal monitoring to be used for a laboring client. The fetal part does not have to be engaged. The cervix needs to be dilated in order to insert the device. Any presentation is acceptable.

1. The nurse assesses a laboring client who is dilated 6 cm and is becoming more intense and more tired. Which phase of labor represents this type of response? a. Transition. b. Latent. c. Second. d. Active.

ANS: D 1. Active Rationale: During the latent phase of labor the client is dilated from 0 to 3 cm, is relaxed, and is excited, yet anxious. In the active phase, the cervix is dilated 4 to 7 cm and the client becomes more intense and begins to tire. In the transition phase, the cervix is dilated from 9 to 10 cm and the client may be unable to cope and will need frequent coaching. There is no second phase.

10. The nurse is caring for a client at 37 weeks' gestation who has pregnancy-induced hypertension and is in the active phase of labor. How frequently should the nurse assess the fetal heart rate? a. Every 30 minutes. b. Every 5 minutes. c. Every hour. d. Every 15 minutes.

ANS: D 10. Every 15 minutes. Rationale: Assessing the fetal heart rate every 15 minutes is appropriate for a high-risk patient in active labor. Assessing the fetal heart rate every 5 minutes is appropriate for high-risk clients in the second stage of labor. Every 30 minutes is appropriate in the latent phase for high-risk clients; and every hour is appropriate in the latent phase for low-risk clients.

3. A client is admitted to the birthing center with possible rupture of membranes. What substance in the fluid could contribute to a false positive reading on Nitrazine test tape? a. Bacteria. b. Feces. c. Meconium. d. Lubricant.

ANS: D 3. Lubricant. Rationale: Lubricant in the fluid could contribute to a false positive reading on Nitrazine test tape. Feces, bacteria, or meconium in the fluid will not alter the test results.

5. A nurse is receiving a report on four clients in the birthing center. Which client should the nurse anticipate giving birth first? a. G2P1, 5 cm dilated, and 40% effaced. b. G1P0, 4 cm dilated, and 80% effaced. c. G6P0, 6 cm dilated, and 50% effaced. d. G5P4, 5 cm dilated, and 40% effaced.

ANS: D 5. G5P4, 5 cm dilated, and 40% effaced. Rationale: The client who is G5P4, 5 cm dilated, and 40% effaced probably will be the first to deliver. Multiparas usually progress faster than nulliparas. A gravida 6 with no prior delivery likely will not progress as rapidly as the woman who is gravida 5 para 4.

8. The fetal monitor has shown several late decelerations over the past 10 minutes. The nurse determines that this pattern indicates: a. Maternal fever. b. Umbilical cord compression. c. Head compression. d. Fetal hypoxia.

ANS: D 8. Fetal hypoxia. Rationale: A pattern of late decelerations indicates fetal hypoxia, caused primarily by uteroplacental insufficiency. Variable decelerations are caused by umbilical cord compression. Early decelerations are caused by head compression. Maternal fever can contribute to fetal tachycardia.

9. The nurse has auscultated a fetal heart rate of 80. What should the nurse's initial action be? a. Position the client on her left side. b. Administer oxygen at 5 L per minute. c. Notify the physician or nurse-midwife. d. Check the maternal pulse.

ANS: D 9. Check the maternal pulse. Rationale: The nurse should check the maternal pulse, because the rate of 80 could be the maternal heart rate rather than the fetal heart rate. Positioning the client on her left side, administering oxygen at 5 L per minute, and notifying the physician or nurse-midwife would be appropriate only if the rate of 80 (fetal bradycardia) were confirmed to be the fetal heart rate.