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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) Start pitocin
b) Insert a Foley catheter
c) Call for help.
d) Notify the care provider immediately
a) Notify the care provider immediately
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 baby’s heart rate should be. Your best response is:
a) “Your doctor will explain all of that later.”
b) “The top line graphs the baby’s 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) “Don’t worry about that machine; that’s my job.”
d) “The top line graphs the baby’s heart rate, and the bottom line lets me know how strong the contractions are.”
A nurse might be called on to stimulate the fetal scalp:
a) In response to tocolysis.
b) To elicit an acceleration in the fetal heart rate (FHR).
c) As part of fetal scalp blood sampling.
d) In preparation for fetal oxygen saturation monitoring
a) To elicit an acceleration in the fetal heart rate (FHR).
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:
a) Change in position.
b) Intravenous analgesic.
c) Regional anesthesia.
d) Oxytocin administration.
Change in position.
According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR):
a) Before and after ambulation and rupture of membranes.
b) Every 15 minutes in the active phase of the first stage of labor in the absence of risk factors
c) More often in a woman’s first pregnancy
d) Every 20 minutes in the second stage, regardless of whether risk factors are present.
Which fetal heart rate (FHR) finding would concern the nurse during labor?
a) Early decelerations
b) Accelerations with fetal movement
c) Late decelerations
d) An average FHR of 126 beats/min
Which deceleration of the fetal heart rate would NOT require the nurse to change the maternal position?
a) It is always a good idea to change the woman’s position
b) Early decelerations
c) Variable decelerations
d) Late decelerations
The nurse caring for the laboring woman should understand that early decelerations are caused by:
a) Umbilical cord compression.
b) Uteroplacental insufficiency.
c) Altered fetal cerebral blood flow
d) Spontaneous rupture of membranes.
Fetal bradycardia is most common during
a) Tocolytic treatment using ritodrine.
b) Intraamniotic infection
c) Prolonged umbilical cord compression.
d) Fetal anemia.
The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate might be caused by:
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 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.
A normal uterine activity pattern in labor is characterized by:
a) Contractions every 2.5 to 5 minutes.
b) Contractions lasting about 2 minutes.
c) A contraction intensity of about 1000 mm Hg with relaxation at 50 mm Hg.
d) Contractions about 1 minute apart.
Contractions every 2.5 to 5 minutes.
The nurse caring for a woman in labor understands that prolonged decelerations:
a) Constitute a baseline change when they last longer than 5 minutes.
b) Are a continuing pattern of benign decelerations that do not require intervention
c) Require the usual fetal monitoring by the nurse.
d) Usually are isolated events that end spontaneously.
Usually are isolated events that end spontaneously.
In assisting with the two factors that have an effect on fetal status (i.e., pushing and positioning), nurses should:
a) Advise the woman to avoid the semi-Fowler position.
b) Instruct the woman to open her mouth and close her glottis, letting air escape after the push.
c) Encourage the woman’s cooperation in avoiding the supine position
d) Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response.
What is an advantage of external electronic fetal monitoring?
a) The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs).
b) Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.
c) The external EFM can accurately record FHR all the time.
d) The external EFM does not require rupture of membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring.
Which of the following is NOT a reassuring component of the fetal heart rate
a) Absent FHR Variability
b) FHR of 114
c) Accelerations of the FHR
d) Moderate Variability
Absent FHR Variability
Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when:
a) The woman involuntarily tries to bear down.
b) Bloody show increases.
c) The nurse is unable to feel the cervix during a vaginal examination.
d) The woman has a sudden episode of vomiting.
After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to:
a) Initiate the lactation cycle.
b) Prevent neonatal hypoglycemia.
c) Stimulate the uterus to contract.
d) Facilitate maternal-newborn interaction.
If a woman complains of back labor pain, the nurse might best suggest that she:
a) Take some deep, cleansing breaths.
b) Lie on her back for a while with her knees bent.
c) Do less walking around.
d) Lean over a birth ball with her knees on the floor.
The nurse knows that the second stage of labor, the descent phase, has begun when:
a) The presenting part is below the ischial spines.
b) The cervix cannot be felt during a vaginal examination and she has an urge to push.
c) The amniotic membranes rupture.
d) The woman experiences a strong urge to bear down and she is 8 cm dilated.
The cervix cannot be felt during a vaginal examination and she has an urge to push.
In documenting labor experiences, nurses should know that a uterine contraction is described according to all of these characteristics EXCEPT:
a) Intensity (the strength of the contraction at its peak).
b) Resting tone (the tension in the uterine muscle).
c) Frequency (how often contractions occur).
d) Appearance (shape and height).
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be:
a) Dilation of the cervix.
b) Increase in bloody show.
c) Rupture of the amniotic membranes.
d) Descent of the fetus.
The most critical nursing action in caring for the newborn immediately after birth is:
a) Fostering parent-newborn attachment.
b) Drying the newborn and wrapping the infant in a blanket.
c) Drying the baby, stimulating respirations, and assessing the respiratory status, keeping the baby warm..
d) Administering eye drops and vitamin K.
As part of the physical examination component of assessment, Leopold maneuvers are used to help identify all of the following except the:
a) Number of fetuses.
b) Fetal lie and attitude.
c) Gender of the fetus.
d) Degree of the presenting part’s descent into the pelvis.
Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as:
a) Second stage, latent phase
b) First stage, latent phase
c) First stage, transition phase
d) First stage, active phase
Which description of the phases of the second stage of labor is accurate?
a) Latent phase: Feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes
b) Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varies
c) Transitional phase: Woman “laboring down,” fetal station is 0, duration is 15 minutes
d) Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes
Concerning the third stage of labor, nurses should be aware that:
a) The placenta eventually detaches itself from a flaccid uterus
b) The major risk for women during the third stage is a rapid heart rate.
c) It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface.
d) An expectant or active approach to managing this stage of labor reduces the risk of complications
An expectant or active approach to managing this stage of labor reduces the risk of complications
When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman’s fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that:
a) Clots have formed in the upper uterine segment.
b) A cervical tear occurred during the birth
c) The woman is beginning to hemorrhage.
d) The placenta has separated
When a woman pregnant with her first baby telephones the hospital to report that she is in labor, the nurse initially should:
a) Arrange for the woman to come to the hospital for labor evaluation.
b) Tell the woman to stay home until her membranes rupture.
c) Ask the woman to describe why she believes she is in labor.
d) Emphasize that food and fluid intake should stop.
The nurse recognizes that a woman is in true labor when she states:
a) “My bag of waters just broke.”
b) My baby dropped, and I have to urinate more frequently now.”
c) “I passed some thick, pink mucus when I urinated this morning.”
d) “The contractions in my uterus are getting stronger and closer together.”
Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions?
a) Evaluate the intensity by pressing the fingertips into the uterine fundus at rest and during the contraction
b) Assess uterine contractions every 30 minutes throughout the first stage of labor
c) Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips.
d) Determine the frequency by timing from the end of one contraction to the end of the next contraction.
Which statement correctly describes the effects of various pain factors?
a) Upright positions in labor increase the pain factor because they cause greater fatigue.
b) Levels of pain-mitigating -endorphins are higher during a spontaneous, natural childbirth
c) Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth
d) Women who move around trying different positions are experiencing more pain
A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. This procedure is:
a) Not used much anymore
b) A prelude to cesarean birth.
c) An application of nitrous oxide.
d) Likely to be used in the second stage of labor but not in the first stage.
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