Deck 17: Intrapartum Nursing Assessment

Question 1

While palpating contractions, the nurse determines that a client is in the latent phase of labor. What findings did the nurse use to make this determination? Select all that apply.
1) Contractions rated as being moderate to strong
2) Contractions rated as being mild to moderate
3) Contractions occur every 6 minutes lasting for 40 seconds
4) Contractions occur every 2 minutes lasting for 50 seconds
5) Contraction occurs every 10 minutes lasting for 30 seconds

Answer 1

2, 3, 5

Question 2

The nurse is admitting a client to the labor and delivery unit. Which aspect of the history requires notifying the healthcare provider?
1) Blood pressure 120/88
2) Dark red vaginal bleeding
3) History of domestic abuse
4) Father is a carrier of sickle-cell trait

Answer 2

2

Question 3

Which pattern, if seen on an electronic fetal monitoring strip, should the nurse explain to a client in labor as being a change in the baseline fetal heart rate?
1) Tachycardia
2) Acceleration
3) Late deceleration
4) Sinusoidal pattern

Answer 3

1

Question 4

The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first?
1) Facilitate a maternal left lateral position.
2) Alert the healthcare provider of the fetal status.
3) Decrease the rate of infusion of intravenous fluids.
4) Administer oxygen to the client at 4 L per minute via nasal cannula.

Question 5

The nurse is preparing to assess the fetus of a laboring client. Which should the nurse perform first?
1) Place the client into a left lateral position.
2) Perform the Leopold maneuver to determine fetal position.
3) Dry the maternal abdomen before using the Doppler.
4) Count the fetal heart rate for 30 seconds and multiply by 2.

Question 6

The nurse explains to a client in labor that the fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement about the most important part of fetal heart monitoring indicates that the client understands the nurse's teaching?
1) "Presence of variability"
2) "Depth of decelerations"
3) "Fetal heart rate baseline"
4) "Absence of variable decelerations"

Question 7

The nurse is caring for a high-risk client in the second stage of labor. After which actions should the nurse assess the fetal heart rate? Select all that apply.
1) Vaginal examination
2) Urinary catheterization
3) Ingestion of clear liquids
4) Administration of pain medication
5) Change in oxytocin administration

Question 8

The fetal heart rate baseline is 140 beats per minute. 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?
1) Determine the color of the leaking amniotic fluid.
2) Apply oxygen to the client at 2 L per nasal cannula.
3) Notify the operating room of the need for a cesarean birth.
4) Assist the client to change from the Fowler position to the left lateral position.

Question 9

A client's fetal heart rate has a sinusoidal pattern. What should the nurse consider as being the reason for this pattern? Select all that apply.
1) Fetal anemia
2) Chronic fetal bleed
3) Severe fetal hypoxia
4) Maternal hypotension
5) Umbilical cord compression

Question 10

A low-risk client is in the second stage of labor. What actions should the nurse take regarding the auscultation of this client's fetal heart rate? Select all that apply.
1) Evaluate after ambulation.
2) Assess heart sounds every 15 minutes.
3) Evaluate before the membrane rupture.
4) Evaluate before providing medications.
5) Count for 30 seconds and multiply times 2.

Question 11

The nurse is explaining Leopold maneuvers to a client who is in the early stage of labor. What should the nurse explain as being the purpose of the second maneuver?
1) Locate the fetal back
2) Identify the descent of the presenting part into the pelvis
3) Determine if the pelvic inlet contains the head or buttocks
4) Determine if the fetal head or buttocks occupies the uterine fundus

Question 12

The nurse is observing a student provide care to a client who is in early labor. Which student actions should be corrected?
1) Applying a fetal heart monitor followed by an explanation of the reason for its use
2) Upon entering the room, speaking with the client prior to looking at the fetal heart monitor
3) Using layman's terms to provide the client with an explanation of the reason for electronic fetal monitoring
4) Incorporating cues that arise from intuition or from observations of the client and family as opposed to focusing on the fetal heart monitor

Question 13

The student nurse is performing Leopold maneuvers on a client in labor. For which action should the staff nurse intervene?
1) After determining where the back is located, the cervix is assessed.
2) The upper portion of the uterus is palpated, and then the middle section.
3) Following voiding, the client's abdomen is palpated from top to bottom.
4) The client is assisted into the supine position, and the position of the fetus is assessed.

Question 14

The nurse is preparing to monitor the fetal heart rate (FHR) of a pregnant client. What should the nurse explain to a nursing student as being the baseline (BL) of this heart rate?
1) "The baseline FHR excludes periods of marked variability."
2) "Normal baseline FHR ranges from 100 to 180 beats per minute."
3) "The baseline FHR should include periodic or episodic changes in FHR."
4) "The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute."

Question 15

A client's fetal heart rate tracing has a consistent late deceleration pattern. What actions should the nurse take at this time? Select all that apply.
1) Prepare for cesarean birth.
2) Increase intravenous fluids.
3) Monitor maternal blood pressure.
4) Position client on the left side.
5) Apply oxygen 7 to 10 L via face mask.

Question 16

During an antenatal examination the nurse becomes concerned that the client is at high risk. What findings did the nurse use to make this clinical determination? Select all that apply.
1) Smokes one half pack per day of cigarettes
2) Employer provides maternal leave of absence
3) Is estranged from family and the baby's father
4) Loss of 3 lb since last examination 1 month ago
5) Treated for a sexually transmitted infection (STI) 2 months ago

Question 17

The nurse categorizes a client's fetal heart rate tracing as a level 2. What criteria were used for this categorization? Select all that apply.
1) Tachycardic baseline.
2) Decelerations lasted longer than 2 minutes.
3) Scalp stimulation did not effect acceleration.
4) Absent variability with recurrent late decelerations.
5) Variable decelerations that slowly return to baseline.

Question 18

A client's amniotic fluid is meconium stained. What should the nurse do immediately?
1) Change the client's position in bed.
3) Administer oxygen at 2 L per minute.
2) Notify the healthcare provider that birth is imminent.
4) Begin continuous fetal heart rate monitoring.

Question 19

The nurse is preparing to assess a client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed?
1) "When you check my cervix, you will find out how thinned out it is."
2) "After you assess my pelvis, you will be able to tell when I will deliver."
3) "You are going to do a vaginal examination to see how far dilated my cervix is."
4) "The reason for a pelvic examination is to determine how low in the pelvis my baby is."

Question 20

The client in labor with meconium-stained amniotic fluid asks why the fetal monitor is necessary because the belt is uncomfortable. What should the nurse explain about monitoring?
1) "It helps us to see how the baby is tolerating labor."
2) "It can be removed, and oxygen can be given instead."
3) "It is necessary so we can see how your labor is progressing."
4) "It will prevent complications from the meconium in your fluid."