Chapter 15: Fetal Assessment during Labor Nursing School Test Banks

Chapter 15: Fetal Assessment during Labor

MULTIPLE CHOICE

1. Fetal bradycardia is most common during:

a.

Intraamniotic infection.

b.

Fetal anemia.

c.

Prolonged umbilical cord compression.

d.

Tocolytic treatment using terbutaline.

ANS: C

Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 390

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

2. While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurses first priority is to:

a.

Change the womans position.

c.

Assist with amnioinfusion.

b.

Notify the care provider.

d.

Insert a scalp electrode.

ANS: A

Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, the nurse would continue with subsequent intrauterine resuscitation measures, including notifying the care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely reveals variable deceleration. A fetal scalp electrode would provide accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurses first priority.

PTS: 1 DIF: Cognitive Level: Application REF: 392

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

3. The nurse caring for the laboring woman should understand that early decelerations are caused by:

a.

Altered fetal cerebral blood flow.

c.

Uteroplacental insufficiency.

b.

Umbilical cord compression.

d.

Spontaneous rupture of membranes.

ANS: A

Early decelerations are the fetuss response to fetal head compression. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal heart rate unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 391

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. The nurse providing care for the laboring woman comprehends that accelerations with fetal movement:

a.

Are reassuring.

b.

Are caused by umbilical cord compression.

c.

Warrant close observation.

d.

Are caused by uteroplacental insufficiency.

ANS: A

Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 390

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

5. The nurse providing care for the laboring woman realizes that variable fetal heart rate (FHR) decelerations are caused by:

a.

Altered fetal cerebral blood flow.

c.

Uteroplacental insufficiency.

b.

Umbilical cord compression.

d.

Fetal hypoxemia.

ANS: B

Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the FHR. Fetal hypoxemia would result in tachycardia initially and then bradycardia if hypoxia continues.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 393

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are the result of:

a.

Altered cerebral blood flow.

c.

Uteroplacental insufficiency.

b.

Umbilical cord compression.

d.

Meconium fluid.

ANS: C

Uteroplacental insufficiency would result in late decelerations in the FHR. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Umbilical cord compression would result in variable decelerations in the FHR. Meconium-stained fluid may or may not produce changes in the fetal heart rate, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 398

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat:

a.

Variable decelerations.

c.

Fetal bradycardia.

b.

Late decelerations.

d.

Fetal tachycardia.

ANS: A

Amnioinfusion is used during labor either to dilute meconium-stained amniotic fluid or to supplement the amount of amniotic fluid to reduce the severity of variable decelerations caused by cord compression. Amnioinfusion has no bearing on late decelerations, fetal bradycardia, or fetal tachycardia alterations in fetal heart rate (FHR) tracings.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 396

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

8. The nurse caring for the woman in labor should understand that maternal hypotension can result in:

a.

Early decelerations.

c.

Uteroplacental insufficiency.

b.

Fetal dysrhythmias.

d.

Spontaneous rupture of membranes.

ANS: C

Low maternal blood pressure reduces placental blood flow during uterine contractions and results in fetal hypoxemia. Maternal hypotension is not associated with early decelerations, fetal dysrhythmias, or spontaneous rupture of membranes.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 394

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:

a.

Change in position.

c.

Regional anesthesia.

b.

Oxytocin administration.

d.

Intravenous analgesic.

ANS: A

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 womans 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, regional anesthesia, and intravenous analgesic may reduce maternal cardiac output.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 396

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

10. While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:

a.

Change the womans position.

b.

Discontinue the oxytocin infusion.

c.

Insert an internal monitor.

d.

Document the finding in the clients record.

ANS: D

The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings.

PTS: 1 DIF: Cognitive Level: Application REF: 399

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

11. Which fetal heart rate (FHR) finding would concern the nurse during labor?

a.

Accelerations with fetal movement

c.

An average FHR of 126 beats/min

b.

Early decelerations

d.

Late decelerations

ANS: D

Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected. Accelerations in the FHR are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they generally are not a concern during normal labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 383

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is:

a.

Altered cerebral blood flow.

c.

Umbilical cord compression.

b.

Fetal hypoxemia.

d.

Fetal sleep cycles.

ANS: D

A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Fetal hypoxemia would be evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be seen. Umbilical cord compression would result in variable decelerations in the FHR.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 390

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

13. 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 above 110 beats/min.

ANS: A

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 above 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information would be needed to determine fetal well-being.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 400

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. 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 intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?

a.

Scream for help.

b.

Insert a Foley catheter.

c.

Start Pitocin.

d.

Notify the care provider immediately.

ANS: D

To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. Pitocin may place additional stress on the fetus.

PTS: 1 DIF: Cognitive Level: Evaluation REF: 395

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

15. What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken.

a.

Call the provider, reposition the mother, and perform a vaginal examination.

b.

Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.

c.

Administer oxygen to the mother, increase IV fluid, and notify the care provider.

d.

Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.

ANS: B

Repositioning the mother, increasing intravenous (IV) fluid, and providing oxygen via face mask are correct nursing actions for intrauterine resuscitation. The nurse should initiate intrauterine resuscitation in an ABC manner, similar to basic life support. The first priority is to open the maternal and fetal vascular systems by repositioning the mother for improved perfusion. The second priority is to increase blood volume by increasing the IV fluid. The third priority is to optimize oxygenation of the circulatory volume by providing oxygen via face mask. If these interventions do not resolve the fetal heart rate issue quickly, the primary provider should be notified immediately.

PTS: 1 DIF: Cognitive Level: Evaluation REF: 396

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

16. Perinatal nurses are legally responsible for:

a.

Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes.

b.

Greeting the client on arrival, assessing her, and starting an intravenous line.

c.

Applying the external fetal monitor and notifying the care provider.

d.

Making sure that the woman is comfortable.

ANS: A

Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions. Greeting the client, assessing her, and starting an IV; applying the external fetal monitor and notifying the care provider; and making sure the woman is comfortable may be activities that a nurse performs, but they are not activities for which the nurse is legally responsible.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 396

OBJ: Nursing Process: Assessment, Planning, Implementation

MSC: Client Needs: Safe and Effective Care Environment

17. As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations or loss of variability is nonreassuring and is associated with:

a.

Hypotension.

c.

Maternal drug use.

b.

Cord compression.

d.

Hypoxemia.

ANS: D

Nonreassuring heart rate patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Fetal variable decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 390

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

18. A new client and her partner arrive on the labor, delivery, recovery, and postpartum unit for the birth of their first child. You apply the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the babys heart rate should be. Your best response is:

a.

Dont worry about that machine; thats my job.

b.

The top line graphs the babys heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor.

c.

The top line graphs the babys heart rate, and the bottom line lets me know how strong the contractions are.

d.

Your doctor will explain all of that later.

ANS: B

The top line graphs the babys heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor educates the partner about fetal monitoring and provides support and information to alleviate his fears. Dont worry about that machine; thats my job discredits the partners feelings and does not provide the teaching he is requesting. The top line graphs the babys heart rate, and the bottom line lets me know how strong the contractions are provides inaccurate information and does not address the partners concerns about the fetal heart rate. The EFM graphs the frequency and duration of the contractions, not the intensity. Nurses should take every opportunity to provide client and family teaching, especially when information is requested.

PTS: 1 DIF: Cognitive Level: Application REF: 397

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

19. A normal uterine activity pattern in labor is characterized by:

a.

Contractions every 2 to 5 minutes.

b.

Contractions lasting about 2 minutes.

c.

Contractions about 1 minute apart.

d.

A contraction intensity of about 1000 mm Hg with relaxation at 50 mm Hg.

ANS: A

Contractions normally occur every 2 to 5 minutes and last less than 90 seconds (intensity 800 mm Hg) with about 30 seconds in between (20 mm Hg or less).

PTS: 1 DIF: Cognitive Level: Knowledge REF: 383

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

20. According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR):

a.

Every 15 minutes in the active phase of the first stage of labor in the absence of risk factors.

b.

Every 20 minutes in the second stage, regardless of whether risk factors are present.

c.

Before and after ambulation and rupture of membranes.

d.

More often in a womans first pregnancy.

ANS: C

The FHR should be auscultated before and after administration of medications and induction of anesthesia. In the active phase of the first stage of labor, the FHR should be auscultated every 30 minutes if no risk factors are involved; with risk factors it should be auscultated every 15 minutes. In the second stage of labor the FHR should be auscultated every 15 minutes if no risk factors are involved; with risk factors it should be auscultated every 5 minutes. The fetus of a first-time mother is automatically at greater risk.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 385

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

21. When using intermittent auscultation (IA) for fetal heart rate, nurses should be aware that:

a.

They can be expected to cover only two or three clients when IA is the primary method of fetal assessment.

b.

The best course is to use the descriptive terms associated with electronic fetal monitoring (EFM) when documenting results.

c.

If the heartbeat cannot be found immediately, a shift must be made to EFM.

d.

Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.

ANS: D

Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if ultrasound is used to help locate the heartbeat. When used as the primary method of fetal assessment, auscultation requires a nurse-to-client ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 384

OBJ: Nursing Process: Assessment, Planning

MSC: Client Needs: Health Promotion and Maintenance

22. When using intermittent auscultation (IA) to assess uterine activity, the nurse should be cognizant that:

a.

The examiners hand should be placed over the fundus before, during, and after contractions.

b.

The frequency and duration of contractions is 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.

ANS: A

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.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 385

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. What is an advantage of external electronic fetal monitoring?

a.

The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the fetal heart rate.

b.

The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs).

c.

The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor.

d.

Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.

ANS: C

The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor, particularly when the membranes are intact. Short-term changes cannot be measured with this technology. The tocotransducer cannot measure and record the intensity of UCs. The transducer must be repositioned when the woman or fetus changes position.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 385

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

24. When assessing the relative advantages and disadvantages of internal and external electronic fetal monitoring, nurses comprehend that both:

a.

Can be used when membranes are intact.

b.

Measure the frequency, duration, and intensity of uterine contractions.

c.

May need to rely on the woman to indicate when uterine activity (UA) is occurring.

d.

Can be used during the antepartum and intrapartum periods.

ANS: D

External monitoring can be used in both periods; internal monitoring can be used only in the intrapartum period. For internal monitoring the membranes must have ruptured, and the cervix must be sufficiently dilated. Internal monitoring measures the intensity of contractions; external monitoring cannot do this. With external monitoring, the woman may need to alert the nurse that UA is occurring; internal monitoring does not require this.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 385

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

25. During labor a fetus with an average heart rate of 135 beats/min over a 10-minute period would be considered to have:

a.

Bradycardia.

c.

Tachycardia.

b.

A normal baseline heart rate.

d.

Hypoxia.

ANS: B

The baseline heart rate is measured over 10 minutes; a normal range is 110 to 160 beats/min. Bradycardia is a fetal heart rate (FHR) below 110 beats/min for 10 minutes or longer. Tachycardia is an FHR over 160 beats/min for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of this condition exists with a baseline heart rate in the normal range.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 389

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

26. The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate may be caused by:

a.

Narcotics.

c.

Methamphetamines.

b.

Barbiturates.

d.

Tranquilizers.

ANS: C

Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; methamphetamines may cause increased variability.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 390

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

27. Which deceleration of the fetal heart rate would not require the nurse to change the maternal position?

a.

Early decelerations

b.

Late decelerations

c.

Variable decelerations

d.

It is always a good idea to change the womans position.

ANS: A

Early decelerations (and accelerations) generally do not need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral); variable decelerations also require a maternal position change (side to side). Although changing positions throughout labor is recommended, it is not required in response to early decelerations.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 391

OBJ: Nursing Process: Assessment, Planning

MSC: Client Needs: Physiologic Integrity

28. What correctly matches the type of deceleration with its likely cause?

a.

Early decelerationumbilical cord compression

b.

Late decelerationuteroplacental inefficiency

c.

Variable decelerationhead compression

d.

Prolonged decelerationcause unknown

ANS: B

Late deceleration is caused by uteroplacental inefficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 392

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

29. The nurse caring for a woman in labor understands that prolonged decelerations:

a.

Are a continuing pattern of benign decelerations that do not require intervention.

b.

Constitute a baseline change when they last longer than 5 minutes.

c.

Usually are isolated events that end spontaneously.

d.

Require the usual fetal monitoring by the nurse.

ANS: C

Prolonged decelerations usually are isolated events that end spontaneously. However, in certain combinations with late and/or variable decelerations, they are a danger sign that requires the nurse to notify the physician or midwife immediately. A deceleration that lasts longer than 10 minutes constitutes a baseline change.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 393

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

30. A nurse may be called on to stimulate the fetal scalp:

a.

As part of fetal scalp blood sampling.

b.

In response to tocolysis.

c.

In preparation for fetal oxygen saturation monitoring.

d.

To elicit an acceleration in the fetal heart rate (FHR).

ANS: D

The scalp can be stimulated using digital pressure during a vaginal examination. Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse would stimulate the fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxation of the uterus. Fetal oxygen saturation monitoring involves the insertion of a sensor.

PTS: 1 DIF: Cognitive Level: Application REF: 396

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

31. In assisting with the two factors that have an effect on fetal status (i.e., pushing and positioning), nurses should:

a.

Encourage the womans cooperation in avoiding the supine position.

b.

Advise the woman to avoid the semi-Fowler position.

c.

Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response.

d.

Instruct the woman to open her mouth and close her glottis, letting air escape after the push.

ANS: A

The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. The Valsalva maneuver, which encourages the woman to hold her breath and tighten her abdominal muscles, should be avoided. Both the mouth and glottis should be open, letting air escape during the push.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 399

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

32. The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:

a.

Notify the womans primary health care provider immediately.

b.

Prepare to administer an oxytocic to stimulate uterine activity.

c.

Document the findings because they reflect the expected contraction pattern for the active phase of labor.

d.

Prepare the woman for the onset of the second stage of labor.

ANS: C

The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse would document these findings in the clients medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary care provider at this time.

Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

PTS: 1 DIF: Cognitive Level: Application REF: 399

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

33. Which maternal condition is considered a contraindication for the application of internal monitoring devices?

a.

Unruptured membranes

c.

External monitors in current use

b.

Cervix dilated to 4 cm

d.

Fetus with a known heart defect

ANS: A

In order to apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm permits the insertion of fetal scalp electrodes and intrauterine catheter. The external monitor can be discontinued after the internal ones are applied. A compromised fetus should be monitored with the most accurate monitoring devices.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 386

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

34. The nurse knows that proper placement of the tocotransducer for electronic fetal monitoring is located:

a.

Over the uterine fundus.

c.

Inside the uterus.

b.

On the fetal scalp.

d.

Over the mothers lower abdomen.

ANS: A

The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 386

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

35. Why is continuous electronic fetal monitoring usually used when oxytocin is administered?

a.

The mother may become hypotensive.

b.

Uteroplacental exchange may be compromised.

c.

Maternal fluid volume deficit may occur.

d.

Fetal chemoreceptors are stimulated.

ANS: B

The uterus may contract more firmly, and the resting tone may be increased with oxytocin use. This response reduces entrance of freshly oxygenated maternal blood into the intervillous spaces, thus depleting fetal oxygen reserves. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk. Oxytocin affects the uterine muscles.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 382

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

36. Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by:

a.

Maintaining normal maternal temperature.

b.

Preventing normal maternal hypoglycemia.

c.

Increasing the oxygen-carrying capacity of the maternal blood.

d.

Expanding maternal blood volume.

ANS: D

Filling the mothers vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most intravenous fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

PTS: 1 DIF: Cognitive Level: Application REF: 396

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

37. A tiered system of categorizing FHR has been recommended by regulatory agencies. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. These categories include (Select all that apply):

a.

Reassuring.

b.

Category I.

c.

Category II.

d.

Nonreassuring.

e.

Category III.

ANS: B, C, E

The three tiered system of FHR tracings include Category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate. This category includes tracings that do not meet Category I or III criteria. Category III tracings are abnormal and require immediate intervention.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 396

OBJ: Nursing Process: Assessment, Planning

MSC: Client Needs: Physiologic Integrity

38. The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patients most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration (Select all that apply)?

a.

Spontaneous fetal movement

b.

Compression of the fetal head

c.

Placental abruption

d.

Cord around the babys neck

e.

Maternal supine hypotension

ANS: C, E

Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the umbilical cord is around the babys neck, arm, leg, or other body part or when there is a short cord, a knot in the cord, or a prolapsed cord.

PTS: 1 DIF: Cognitive Level: Analysis REF: 393

OBJ: Nursing Process: Assessment, Diagnosis

MSC: Client Needs: Physiologic Integrity

MATCHING

Fetal well-being in labor can be measured by the response of the FHR to uterine contractions. Please match the characteristic of normal uterine activity during labor with the correct description.

a.

Frequency

d.

Resting tone

b.

Duration

e.

Relaxation time

c.

Strength

39. Commonly 45 seconds or more in the second stage of labor

40. Generally ranging from two to five contractions per 10 minutes of labor

41. Average of 10 mm Hg

42. Peaking at 40 to 70 mm Hg in the first stage of labor

43. Remaining fairly stable throughout the first and second stages

39. ANS: E PTS: 1 DIF: Cognitive Level: Evaluation

REF: 383 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Should the FHR respond outside of these evidence-based parameters for uterine activity during labor, intervention may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies seen in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to more than 80 mm Hg in the second stage. Resting tone averages 10 mm Hg, and if using palpation, the uterus should feel soft. In the first stage of labor, relaxation time is commonly 60 seconds or more, and it is 45 seconds or more in the second stage.

40. ANS: A PTS: 1 DIF: Cognitive Level: Evaluation

REF: 383 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Should the FHR respond outside of these evidence-based parameters for uterine activity during labor, intervention may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies seen in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to more than 80 mm Hg in the second stage. Resting tone averages 10 mm Hg, and if using palpation, the uterus should feel soft. In the first stage of labor, relaxation time is commonly 60 seconds or more, and it is 45 seconds or more in the second stage.

41. ANS: D PTS: 1 DIF: Cognitive Level: Evaluation

REF: 383 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Should the FHR respond outside of these evidence-based parameters for uterine activity during labor, intervention may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies seen in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to more than 80 mm Hg in the second stage. Resting tone averages 10 mm Hg, and if using palpation, the uterus should feel soft. In the first stage of labor, relaxation time is commonly 60 seconds or more, and it is 45 seconds or more in the second stage.

42. ANS: C PTS: 1 DIF: Cognitive Level: Evaluation

REF: 383 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Should the FHR respond outside of these evidence-based parameters for uterine activity during labor, intervention may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies seen in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to more than 80 mm Hg in the second stage. Resting tone averages 10 mm Hg, and if using palpation, the uterus should feel soft. In the first stage of labor, relaxation time is commonly 60 seconds or more, and it is 45 seconds or more in the second stage.

43. ANS: B PTS: 1 DIF: Cognitive Level: Evaluation

REF: 383 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic integrity

NOT: Should the FHR respond outside of these evidence-based parameters for uterine activity during labor, intervention may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies seen in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to more than 80 mm Hg in the second stage. Resting tone averages 10 mm Hg, and if using palpation, the uterus should feel soft. In the first stage of labor, relaxation time is commonly 60 seconds or more, and it is 45 seconds or more in the second stage.

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