Question 1

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

Accepted Answer

Late decelerations indicate a decrease in fetal oxygenation and can be a sign of fetal distress. Moderate long-term variability, accelerations, and early decelerations are all normal fetal heart rate patterns.

Question 2

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

A sudden drop in fetal heart rate during contractions followed by a rapid return to baseline can indicate fetal distress caused by changes in blood flow. Changing the mother's position from a sitting to lateral position can improve blood flow to the fetus, making it the best nursing intervention in this situation. Oxygen may be beneficial in certain situations, but it is not the best intervention in this case. A cesarean birth is not immediately necessary based on the information provided. The color of the amniotic fluid is not relevant to this situation.

Question 3

A woman is in labor. The fetus is in vertex position. When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately:

Accepted Answer

Meconium-stained amniotic fluid indicates that the fetus may have passed stool, which can lead to respiratory distress if the stool is aspirated into the lungs during delivery. Therefore, it is important to begin continuous fetal heart rate monitoring to assess fetal distress and to be prepared for emergent delivery assistance if necessary. The other options may be helpful interventions but are not the priority in this situation.

Question 4

The primary care provider is performing a fetal scalp stimulation test. What result would the nurse hope to observe?

Accepted Answer

Fetal scalp stimulation is performed to assess fetal well-being. A healthy response includes fetal heart rate acceleration (B) and reactivity associated with the stimulation (E), indicating a well-oxygenated fetus with an intact central nervous system.

Question 5

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

Accepted Answer

Late decelerations with minimal variability are a concerning finding as they indicate fetal hypoxia and may require immediate intervention such as administering oxygen to the mother or preparing for a potential emergency c-section. Early decelerations are typically benign and do not require intervention, variable decelerations that recover to the baseline are usually also benign but should be closely monitored, and accelerations are a reassuring finding indicating fetal well-being.

Question 6

The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by:

Accepted Answer

Bradycardia can be caused by maternal hypotension, prolonged umbilical cord compression, fetal dysrhythmia, and late fetal asphyxia.

Question 7

The nurse is analyzing fetal cord blood results. If the fetal blood pH is below 7.25, the nurse can conclude that the fetus was:

Accepted Answer

A fetal blood pH below 7.25 indicates that the fetus is experiencing acidosis, which is often a result of hypoxia or decreased oxygen supply. Therefore, the correct choice is A, which specifies that the fetus is both acidotic and hypoxic. Choices B, C, and D are incorrect because they do not accurately reflect the low fetal blood pH level.

Question 8

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 that is not in distress would respond to a fetal scalp stimulation test by showing accelerations on the monitor strip. The test involves applying pressure to the fetal scalp to elicit a fetal heart rate response. If the fetus is healthy and well-oxygenated, the heart rate should increase in response to the stimulation, resulting in accelerations on the monitor strip. If the fetus is in distress or not receiving enough oxygen, it may show late or early decelerations, or decreased variability.

Question 9

The primigravida patient 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 patient's partner asks why the nurse did that. What is the best response by the nurse? "I stimulated the top of the baby's head to:

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 and indicates that the fetus is not in distress.

Question 10

After noting meconium-stained amniotic fluid, fetal heart rate decelerations, and a fetal blood pH of 7.20, the physician diagnoses a severely depressed fetus. The appropriate nursing action at this time would be to:

Accepted Answer

A severely depressed fetus with meconium-stained amniotic fluid, fetal heart rate decelerations, and a low fetal blood pH of 7.20 would require immediate delivery. The options of increasing the mother's oxygen rate or turning her to the left lateral position are appropriate interventions during labor to improve fetal oxygenation but not in the case of a severely depressed fetus. Increasing the intravenous infusion rate may not necessarily improve fetal outcomes. Therefore, preparing the mother for either forceps or cesarean birth would be the most appropriate nursing action to deliver the fetus as quickly and safely as possible.

Question 11

The nurse is caring for a patient who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include:

Accepted Answer

The answer of The nurse is caring for a patient...

Question 12

The primigravida 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 patient understands the nurse's teaching? "The most important part of fetal heart monitoring is the:

Accepted Answer

The presence of variability is the most important part of fetal heart monitoring as it indicates the fetal nervous system is functioning properly. The other options are also important to monitor, but variability is the most crucial.

Question 13

The nurse is caring for a patient in the transition phase of labor, and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation?

Accepted Answer

The fetal heart rate is within normal limits with good variability, indicating the fetus is well-oxygenated. The nurse should provide support and reassurance to the patient and her partner.

Quiz 23: Intrapartum Nursing Assessment