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The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations.
The deceleration begins near the acme of the contraction and continues well beyond the end of
the contraction. Which nursing action indicates the proper evalua
The deceleration begins near the acme of the contraction and continues well beyond the end of
the contraction. Which nursing action indicates the proper evalua
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Which maternal condition should be considered a contraindication for the application of
internal monitoring devices?
internal monitoring devices?
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Exam #3 OB
| Question | Answer |
|---|---|
| The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evalua | This deceleration pattern is associated with uteroplacental insufficiency. The nurse must act quickly to improve placental blood flow and fetal oxygen supply. |
| Which maternal condition should be considered a contraindication for the application of internal monitoring devices? | Unruptured membranes |
| The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? | Fetoscope |
| Proper placement of the tocotransducer for electronic fetal monitoring is | Over the uterine fundus. |
| Which clinical finding can be determined only by electronic fetal monitoring? | Variability |
| Which method of intrapartum fetal monitoring is the most appropriate when a woman has a history of hypertension during pregnancy? | Continuous electronic fetal monitoring |
| Why is continuous electronic fetal monitoring generally used when oxytocin is administered? | Uteroplacental exchange may be compromised. |
| The nurse is concerned that a patient’s uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take? | Obtain an order from the health care provider for an intrauterine pressure catheter. |
| If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen? | Right lower |
| In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding? | The fetus is at 30 weeks of gestation. |
| When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? | Record this normal pattern. |
| When the mother’s membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? | Variable decelerations |
| The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing | an expected response. |
| When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left side, which nursing action is indicated? | Change her position to the right side. |
| Which nursing action is correct when initiating electronic fetal monitoring? | Securely apply the tocotransducer with a strap or belt. |
| Which statement correctly describes the nurse’s responsibility related to electronic monitoring? | Teach the woman and her support person about the monitoring equipment and discuss any of their questions. |
| Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation? | Sympathetic stimulation |
| Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength? | Intrauterine pressure catheter (IUPC) |
| What is the most likely cause for this fetal heart rate pattern? | Cord compression |
| The patient presenting at 38 weeks’ gestation, gravida 1, para 0, vaginal exam 4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern? | Change maternal position. |
| The physician has ordered an amnioinfusion for the laboring patient. Which data supports the use of this therapeutic procedure? | +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) |
| Which of the following is the priority intervention for a supine patient whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? | Reposition to left side-lying position. |
| Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should | maintain the normal assessment routine |
| To clarify the fetal condition when baseline variability is absent, the nurse should first | apply pressure to the fetal scalp with a glove finger using a circular motion. |
| Which patient is a candidate for internal monitoring with an intrauterine pressure catheter? | Obese patient whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds |
| Which of the following is the priority intervention for the patient in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? | Administer O2 at 8 to 10 L/minute. |
| When a pattern of variable decelerations occur, the nurse should immediately | position patient in a knee-chest position. |
| The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient’s | Late decelerations |
| A patient at 41 weeks’ gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse’s prior | Stop the infusion of Pitocin. |
| The nurse admits a laboring patient at term. On review of the prenatal record, the patient’s pregnancy has been unremarkable and she is considered low risk. In planning the patient’s care, at what interval will the nurse intermittently auscultate (IA) the | Every 30 minutes |
| The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? | Administer oxygen with a face mask at 8 to 10 L/minute. |
| The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action at this time? | Perform a vaginal exam to detect a prolapsed cord. |
| Which clinical finding would be considered normal for a preterm fetus during the labor period? | Baseline tachycardia |
| Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.) | All of the above a.Oxytocin (Pitocin) b. Misoprostol (Cytotec) c. Dinoprostone (Cervidil) d. Methylergonovine maleate (Methergine) |
| When evaluating the patient’s progress, the nurse knows that four of the five fetal factors that interact to regulate the heart are(Select all that apply.) | a.baroreceptors. b. adrenal glands. c. chemoreceptors. e. automatic nervous system |
| The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.) | Maternal fever Placenta previa Prolonged rupture of membranes |
| The nurse is preparing supplies for an amnioinfusion on a patient with intact membranes. Which supplies should the nurse gather? (Select all that apply.) | Extra underpads Amniotic hook to perform an amniotomy |
| The nurse is explaining the physiology of uterine contractions to a group of nursing students. Which statement best explains the maternal-fetal exchange of oxygen and waste products during a contraction? | Diminishes as the spiral arteries are compressed |
| The nurse is directing an unlicensed assistive personnel (UAP) to obtain maternal vital signs between contractions. Which statement is the appropriate rationale for assessing maternal vital signs between contractions rather than at another interval? | Maternal circulating blood volume increases temporarily during contractions. |
| Uncontrolled maternal hyperventilation during labor results in | respiratory alkalosis. |
| Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? | Engagement |
| The laboring patient asks the nurse how the labor contractions cause the cervix to dilate. The nurse responds that labor contractions facilitate cervicle dilation by | pulling the cervix over the fetus and amniotic sac. |
| Pregnant patients can usually tolerate the normal blood loss associated with childbirth because of which physiologic adaptation to pregnancy? | Increased blood volume |
| The nurse is assessing the duration of a patient’s labor contractions. Which method does the nurse implement to assess the duration of labor contractions? | Assess from the beginning to the end of each contraction. |
| Which physiologic event is the key indicator of the commencement of true labor? | Cervical dilation and effacement |
| Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? | Flexion |
| An increase in urinary frequency and leg cramps after the 36th week of pregnancy are an indication of | lightening |
| A patient just delivered her baby via the vaginal route. The patient asks the nurse why the baby’s head is not round, but oval. Which explanation should the nurse provide the patient? | This results from molding. |
| A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor? | Active phase |
| The nurse is assessing a patient in the active phase of labor. What should the nurse expect during this phase? | The patient is requesting pain medication. |
| A laboring patient asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement? | The acme |
| A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with | umbilical cord compression. |
| The primary difference between the labor of a nullipara and that of a multipara is | total duration of labor. |
| Which maternal factor may inhibit fetal descent during labor? | A full bladder |
| Which assessment finding would cause a concern for a patient who had delivered vaginally? | Patient complains of fingers tingling |
| On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time? | Notify the health care provider. |
| Which assessment finding indicates that cervical dilation and/or effacement has occurred? | Bloody mucus drainage from vagina |
| If a notation on the patient’s health record states that the fetal position is LSP, this indicates that the | buttocks are in the left posterior quadrant of the pelvis. |
| To determine if the patient is in true labor, the nurse would assess for changes in | cervical dilation |
| The health care provider for a laboring patient makes the following entry into the patient’s record: 3/50%+.. What instruction will the nurse implement with the patient? | Breathe with me slowly, in through your nose and out through your mouth.” |
| The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient? | On her left side |
| The primiparous patient at 39 weeks’ gestation states to the nurse, “I can breathe easier now.” What is the nurse’s most appropriate response? | “That process is called lightening. Do you have to urinate more frequently?” |
| The nurse assesses a laboring patient’s contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 seconds, and the intensity is is moderate by palpation. What is the most accurate documentation for this contraction pattern? | Stage 1, active phase |
| A laboring patient states to the nurse, “I have to push!” What is the next nursing action? | Examine the patient’s cervix for dilation. |
| After birth of the placenta the patient states, “All of a sudden I feel very cold.” What is the most appropriate nursing action at this time? | Place a warm blanket over the patient. |
| A 28-year-old gravida 1, para 0 patient who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet; however, it is not bloody in nature. She relates a contracti | Does she think that her membranes have ruptured? Tell her to come to the hospital for evaluation |
| A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.) | In true labor, the cervix begins to dilate. In true labor, contractions often resemble menstrual cramps during early labor. In true labor your contractions tend to increase in frequency, duration, and intensity with walking. |
| The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.) | Powers Passage Passenger Psyche |
| The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) | Offer the patient a warm blanket. Place an ice pack on the perineum. Massage the uterus if it is boggy. |
| Which clinical finding should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.) | gush of blood appears. The uterus rises upward in the abdomen. The cord descends further from the vagina. |
| The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all t | Natural oxytocin in conjunction with other substances plays a role. Stretching, pressure, and irritation of the uterus and cervix increase. |
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