Question 1

While caring for a client in labor, the nurse notes the following F H R pattern:
Which action should the nurse perform?

Accepted Answer

Continue to monitor the client

Question 2

The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus?

Accepted Answer

A

Question 3

The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first?

Accepted Answer

Leopold maneuvers are performed first to determine the fetal position, which helps in deciding the next steps for fetal assessment and monitoring.

Question 4

After several hours of labor, the electronic fetal monitor (E F M) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following?

Accepted Answer

Repetitive variable decelerations in the fetal heart rate are most commonly associated with umbilical cord compression. This can occur when the cord becomes compressed between the fetus and the maternal pelvis or during contractions, leading to a temporary reduction in blood flow and oxygen to the fetus.

Question 5

The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important?

Accepted Answer

The presence of meconium-stained amniotic fluid can indicate fetal distress, and continuous fetal monitoring is crucial to assess how the baby is tolerating labor, making option C the most important reason for using the monitor.

Question 6

While caring for a client in labor, the nurse notes the following persistent rhythm on the fetal heart rate monitor:
Which action should the nurse take first?

Accepted Answer

Notify the provider because the persistent rhythm on the fetal heart rate monitor indicates a potential problem that requires medical attention.

Question 7

The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician?

Accepted Answer

Dark red vaginal bleeding during admission to the labor and delivery unit is a potential sign of placental abruption or other serious complications, which requires immediate notification of the physician for further assessment and intervention.

Question 8

The nurse is caring for a client undergoing fetal heart rate monitoring, and the F H R is greater than 162 beats/min for 12 minutes. For what cause(s) should the nurse anticipate treatment?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

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

Question 9

The nurse auscultates the F H R and determines a rate of 112 beats/min. Which action is appropriate?

Accepted Answer

A fetal heart rate (FHR) of 112 beats/min is within the normal range of 110-160 beats/min, so it is appropriate to inform the maternal client that the rate is normal.

Question 10

The nurse is reviewing the F H R monitor for a client in labor. The rhythm strip yields the following result:
How should the nurse interpret this pattern?

Accepted Answer

Moderate variability in fetal heart rate is considered normal and indicates a well-oxygenated fetus with a functioning autonomic nervous system.

Question 11

The nurse is assessing the baseline fetal heart rate for a client in labor.
What action should the nurse take first?

Accepted Answer

Measuring the fetal heart rate for 10 minutes is the first step in assessing the baseline fetal heart rate, as it provides a sufficient duration to accurately capture the heart rate's behavior over time.

Question 12

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

Accepted Answer

Meconium-stained amniotic fluid can indicate fetal distress. Continuous fetal heart rate monitoring is crucial to assess the fetus's well-being and detect any signs of distress.

Question 13

The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status?

Accepted Answer

Asking about the labor support person helps the nurse understand the client's support system and emotional preparedness for childbirth, which are key aspects of their psychosocial status.

Question 14

Before performing Leopold maneuvers, what would the nurse do?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of Before performing Leopold maneuvers, what would the...

Question 15

The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse?

Accepted Answer

Leopold maneuvers are used to assess the position and presentation of the fetus, not to assess the cervix. Assessing the cervix is not part of the Leopold maneuvers and requires a different procedure.

Question 16

Upon assessing the F H R tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of Upon assessing the F H R tracing,...

Question 17

The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention?

Accepted Answer

Fetal heart tones should be auscultated more frequently than every 90 minutes, especially as labor progresses, to ensure fetal well-being. Choices B, C, and D describe appropriate monitoring given the circumstances.

Question 18

The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best?

Accepted Answer

The fetal heart rate pattern described is normal, showing accelerations and a slight deceleration during contractions that returns to baseline by the end of the contraction. This indicates good fetal well-being, so the best action is to document the findings.

Question 19

Persistent early decelerations are noted. What would the nurse's first action be?

Accepted Answer

Early decelerations are typically benign and caused by fetal head compression during contractions. They usually do not require intervention.

Question 20

The nurse has just palpated contractions and compares the consistency to that of the forehead in order to estimate the firmness of the fundus. What would the intensity of these contractions be identified as?

Accepted Answer

When contractions are compared to the firmness of the forehead, they are identified as strong. This is a method used to estimate the intensity of uterine contractions during labor, with the softness of the cheek representing mild contractions, the firmness of the chin representing moderate contractions, and the firmness of the forehead representing strong contractions.

Quiz 20: Intrapartum Nursing Assessment

While caring for a client in labor, the nurse notes the following F H R pattern: Which action should the nurse perform?

The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus?

The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first?

After several hours of labor, the electronic fetal monitor (E F M) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following?

The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important?

While caring for a client in labor, the nurse notes the following persistent rhythm on the fetal heart rate monitor: Which action should the nurse take first?

The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician?

The nurse is caring for a client undergoing fetal heart rate monitoring, and the F H R is greater than 162 beats/min for 12 minutes. For what cause(s) should the nurse anticipate treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

The nurse auscultates the F H R and determines a rate of 112 beats/min. Which action is appropriate?

The nurse is reviewing the F H R monitor for a client in labor. The rhythm strip yields the following result: How should the nurse interpret this pattern?

The nurse is assessing the baseline fetal heart rate for a client in labor. What action should the nurse take first?