Question 1

A patient with pregnancy-induced hypertension asks the nurse to please remove the continuous fetal monitor to allow for easier movement.Which is the nurse's best response?&#10;A) &#34;I cannot remove the fetal monitor without a direct order from your provider,and there is an order to keep it on.&#34;&#10;B) &#34;The fetal monitor allows me to make sure the baby is okay during contractions,so we need to leave it on.&#34;&#10;C) &#34;Fetal monitoring restricts movement,but you don't want something to happen to the baby,do you?&#34;&#10;D) &#34;Let me try to adjust the monitor to give you more freedom to move about in bed so you can be more comfortable.&#34;&#10;

Accepted Answer

The nurse acknowledges the patient's request and attempts to find a solution that works for both the patient and the need for fetal monitoring. This allows for patient comfort without compromising the safety of the fetus.

Question 2

Upon admitting a laboring patient,the nurse collects maternal assessment for which purpose?&#10;A) To learn about the patient's medication usage&#10;B) To learn about any complications during the pregnancy&#10;C) To establish a baseline of the patient's condition&#10;D) To determine any cultural needs the patient may have&#10;

Accepted Answer

Collecting a maternal assessment upon admitting a laboring patient allows the nurse to establish a baseline of the patient's condition. This includes obtaining information on the patient's vitals, pain level, previous pregnancies, and any issues during the current pregnancy. This baseline information will help the nurse monitor the patient's progress throughout labor and delivery. While medication usage, complications during pregnancy, and cultural needs are important factors to consider, they are not the primary purpose of the maternal assessment upon admission.

Question 3

The nurse is assisting with the care of multiple patients in labor and recognizes the need to notify the health-care provider for which patient?&#10;A) A primipara whose dilation has progressed from 4 to 5 cm over the past 2 hours&#10;B) A primipara who dilated to 6 cm,and then her contractions stopped&#10;C) A multipara who is 7 cm dilated with an intact amniotic membrane&#10;D) A multipara who is 8 cm dilated and is becoming irritable and restless&#10;

Accepted Answer

A primipara who has dilated to 6 cm and then stopped progressing in labor may be experiencing a complication, such as a cephalopelvic disproportion or a malposition of the fetus, and requires further evaluation by the health-care provider. The other options show progress in labor and do not indicate any immediate concern.

Question 4

The nurse is caring for an obese pregnant woman in preterm labor with intact amniotic membranes who is receiving medications to stop labor.Which type of monitoring is best for this patient?&#10;A) Internal fetal and contraction monitoring&#10;B) Internal fetal and external contraction monitoring&#10;C) External fetal and internal contraction monitoring&#10;D) External fetal and contraction monitoring&#10;

Accepted Answer

External fetal and contraction monitoring would be the best choice for this patient. Internal monitoring carries a higher risk of infection in patients with intact amniotic membranes and the patient's obesity may make internal monitoring technically more difficult.

Question 5

The nurse,while assessing a fetal monitor strip for a woman in term labor,determines there is significant fetal distress when she notes which finding?&#10;A) Fetal heart rate of 160 bpm&#10;B) Moderate variability&#10;C) Accelerations of 25 bpm with contractions&#10;D) Recurrent late decelerations with minimal variability&#10;

Accepted Answer

Recurrent late decelerations with minimal variability indicate uteroplacental insufficiency and compromised fetal oxygenation, which is a significant fetal distress. Fetal heart rate of 160 bpm is within the normal range. Moderate variability and accelerations are signs of fetal well-being.

Question 6

Which statement by the nurse is most appropriate when a patient is reluctant to sign the consent for admission?&#10;A) &#34;Signing this form gives us permission to take care of you.&#34;&#10;B) &#34;If you don't sign this form,we cannot take care of you.&#34;&#10;C) &#34;Everyone admitted to the hospital needs to sign this form.&#34;&#10;D) &#34;It's your choice whether to sign or not sign this form.&#34;&#10;

Accepted Answer

"Signing this form gives us permission to take care of you." is the most appropriate response as it directly addresses the patient's autonomy while explaining the purpose of the consent form in a non-threatening manner.

Question 7

The nurse is caring for a patient who is receiving oxytocin to promote labor and notes late decelerations on the fetal monitor.Which is the nurse's priority of care?&#10;A) Performing Leopold's maneuver to wake the sleeping fetus&#10;B) Administering tocolytics&#10;C) Discontinuing oxytocin&#10;D) Increasing administration of IV fluids&#10;

Accepted Answer

Late decelerations on the fetal monitor indicate fetal distress and are often caused by uteroplacental insufficiency, which means there is not enough blood flow to the fetus. Discontinuing oxytocin, which can contribute to uterine hyperstimulation and compromise fetal oxygenation, is the priority of care in this situation. Administering tocolytics or increasing IV fluids would not address the underlying issue of uteroplacental insufficiency and may even exacerbate the problem. Performing Leopold's maneuver is not indicated for addressing fetal distress.

Question 8

The nurse assesses a fetal heart rate as 190 bpm,with minimal baseline variability and recurring variable decelerations with moderate variability.How does the nurse classify these findings?&#10;A) Category I&#10;B) Category II&#10;C) Category III&#10;D) Falling between category II and category III&#10;

Accepted Answer

These findings are classified as Category II because the fetal heart rate is above the normal range (120-160 bpm), there is minimal baseline variability, and there are recurring variable decelerations with moderate variability. Category II is used for fetal heart rate patterns that do not fit into Category I (normal) or Category III (abnormal and indicative of fetal distress).

Question 9

When analyzing a fetal monitor strip,the nurse recognizes that which decelerations are not an indication for concern and require no nursing interventions?&#10;A) Early decelerations&#10;B) Late decelerations&#10;C) Variable decelerations&#10;D) Absent decelerations&#10;

Accepted Answer

Early decelerations are a normal finding and do not require nursing interventions as they are caused by the fetal head compression during uterine contractions. Late decelerations (B) are a cause for concern as they indicate poor placental perfusion and fetal distress. Variable decelerations (C) can also be a cause for concern as they indicate cord compression. Absent decelerations (D) may indicate a problem with the fetal monitor but could also indicate fetal distress and require further assessment.

Question 10

The nurse performs an assessment of fetal heart rate and determines that the findings indicate a category I on the basis of which assessment finding?&#10;A) Marked baseline variability&#10;B) Recurring late&#10;C) Fetal heart rate of 110 bpm&#10;D) Prolonged decelerations of 5 minutes&#10;

Accepted Answer

Category I fetal heart rate tracings are considered normal and are characterized by a baseline fetal heart rate of 110-160 bpm, moderate baseline variability, no late or variable decelerations, and may include early decelerations or accelerations. A fetal heart rate of 110 bpm falls within the normal range, indicating a Category I finding.

Question 11

While the nurse is talking to a laboring woman,her amniotic membranes rupture.Which is the nurse's priority of care?&#10;A) Vital signs&#10;B) Cervical examination&#10;C) Assessment of fluid&#10;D) Assessment of fetal heart rate&#10;

Accepted Answer

The answer of While the nurse is talking to a...

Question 12

When planning care,the nurse determines that which patient is appropriate for intermittent fetal monitoring?&#10;A) The woman whose pregnancy is at 38 weeks' gestation&#10;B) The woman receiving an epidural anesthetic&#10;C) The woman with controlled gestational diabetes&#10;D) The woman whose 5-year-old was born by Cesarean section&#10;

Accepted Answer

The answer of When planning care,the nurse determines that which...

Question 13

A woman considering options for where to give birth asks the nurse if home birth is safe.Which is the nurse's best response?&#10;A) &#34;Home birth is safe if there are no complications for the mother or infant.&#34;&#10;B) &#34;Home delivery is an option you should talk with the physician about.&#34;&#10;C) &#34;Delivering at home is safe as long as there's a hospital within a 5-minute drive.&#34;&#10;D) &#34;I would never consider delivering my baby at home because of the rate of poor outcomes.&#34;&#10;

Accepted Answer

The answer of A woman considering options for where to...

Question 14

A laboring patient's amniotic membranes rupture,and a sudden variable deceleration is seen on the fetal heart monitor.Which is the nurse's priority action before notifying the health-care provider?&#10;A) Increase IV fluids&#10;B) Perform amniotic infusion&#10;C) Change the patient's position&#10;D) Administer oxygen&#10;

Accepted Answer

The answer of A laboring patient's amniotic membranes rupture,and a...

Question 15

When analyzing a fetal heart strip,the nurse notes the absence of accelerations for the past 15 minutes.Which is the nurse's priority action?&#10;A) Change the maternal position&#10;B) Notify the health-care provider&#10;C) Administer oxygen to the mother&#10;D) Monitor for an additional 15 minutes&#10;

Accepted Answer

The answer of When analyzing a fetal heart strip,the nurse...

Question 16

Under which circumstance does the nurse avoid performing a cervical examination?&#10;A) When the membranes have ruptured&#10;B) When vaginal bleeding is noted&#10;C) When the woman has a multiple pregnancy&#10;D) When the woman has complained of pain on past cervical examinations&#10;

Accepted Answer

The answer of Under which circumstance does the nurse avoid...

Question 17

The nurse reviews the charts of patients who have expressed an interest in home birth and recommends which patient as a potential candidate?&#10;A) A woman whose 1-year-old child was born via Cesarean section&#10;B) A primipara with a history of infertility&#10;C) A woman desiring an epidural for pain control&#10;D) A woman whose last child was stillborn&#10;

Accepted Answer

The answer of The nurse reviews the charts of patients...

Question 18

The nurse admits a laboring patient who is progressing rapidly and says she feels the need to push.Which priority data should be assessed with this patient? (Select all that apply.)&#10;A) Cultural needs&#10;B) Medication history&#10;C) Timing of contractions&#10;D) Cervical dilation&#10;E) Fetal well-being&#10;

Accepted Answer

The answer of The nurse admits a laboring patient who...

Question 19

After Leopold's maneuver is performed,the patient asks the nurse,&#34;Why did you do that?&#34; Which is the nurse's best explanation?&#10;A) &#34;This is a check for fetal well-being.&#34;&#10;B) &#34;This tells me if there will be any complications during delivery.&#34;&#10;C) &#34;I was checking to see what position the fetus is in.&#34;&#10;D) &#34;I was checking to see how you are progressing.&#34;&#10;

Accepted Answer

The answer of After Leopold's maneuver is performed,the patient asks...

Deck 9: Nursing Assessment During Labor