Question 1

The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best?

Accepted Answer

This pattern describes early decelerations of the fetal heart rate, which are typically a normal response to fetal head compression during contractions. Changing the mother's position can help improve fetal circulation and is a common, non-invasive first step in managing early decelerations.

Question 2

The fetus of a laboring patient is in the following position:

What should the nurse expect when conducting the intrapartum vaginal examination?

Accepted Answer

The answer of The fetus of a laboring patient is...

Question 3

A laboring patient being monitored has the following rhythm strip:

How should the nurse interpret this finding?

Accepted Answer

The answer of A laboring patient being monitored has the...

Question 4

Fetal factors that possibly indicate electronic fetal monitoring include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

Meconium passage, multiple gestation, and decreased fetal movement are fetal factors that may indicate the need for electronic fetal monitoring. Meconium passage can suggest fetal distress, multiple gestation increases the risk of complications requiring closer monitoring, and decreased fetal movement may indicate a compromised fetal condition. Preeclampsia and grand multiparity are maternal factors, not fetal factors.

Question 5

The nurse is performing Leopold maneuvers with a patient in the 3rd trimester of pregnancy. Which maneuver should the nurse perform first?

Accepted Answer

The answer of The nurse is performing Leopold maneuvers with...

Question 6

The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse?

Accepted Answer

Fetal scalp stimulation is performed to elicit an acceleration in the fetal heart rate, which is a reassuring sign of fetal well-being.

Question 7

During an intrapartum vaginal examination the nurse palpates the following:
  
Based upon this information, which diagram best describes the fetal descent and station?

Accepted Answer

The answer of During an intrapartum vaginal examination the nurse...

Question 8

The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following?

Accepted Answer

The answer of The nurse is analyzing several fetal heart...

Question 9

The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention?

Accepted Answer

Late decelerations with minimal variability indicate uteroplacental insufficiency and fetal distress, requiring immediate intervention.

Question 10

The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip?

Accepted Answer

A fetus not in distress would show accelerations on the monitor strip in response to fetal scalp stimulation, indicating a healthy response to stimuli and adequate oxygenation.

Question 11

The fetus of a pregnant patient is in the right occiput anterior (R O A) position. Where should the nurse auscultate the fetal heart sounds?

Accepted Answer

The answer of The fetus of a pregnant patient is...

Question 12

After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what?

Accepted Answer

The answer of After noting meconium-stained amniotic fluid and fetal...

Question 13

A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching?

Accepted Answer

The presence of variability in the fetal heart rate is a key indicator of fetal well-being. It suggests that the fetal autonomic nervous system is functioning well, indicating a healthy, non-stressed fetus. Variable decelerations, baseline rate, and depth of decelerations are also important but variability is a primary indicator of fetal status.

Quiz 20: Intrapartum Nursing Assessment

The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best?

The fetus of a laboring patient is in the following position: What should the nurse expect when conducting the intrapartum vaginal examination?

A laboring patient being monitored has the following rhythm strip: How should the nurse interpret this finding?

Fetal factors that possibly indicate electronic fetal monitoring include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected.