Chapter 17: Intrapartum Fetal Surveillance My Nursing Test Banks

Chapter 17: Intrapartum Fetal Surveillance

Test Bank

MULTIPLE CHOICE

1. The nurse sees a pattern on the fetal monitor that looks similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation?

a.

Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction.

b.

This deceleration pattern is associated with uteroplacental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply.

c.

This pattern reflects variable decelerations. No interventions are necessary at this time.

d.

Document this reassuring fetal heart rate pattern, but decrease the rate of the intravenous fluid.

ANS: B

Feedback

A

These are late decelerations, not early; therefore interventions are necessary.

B

This is a description of a late deceleration. Oxygen should be given via snug facemask. Position the woman on her left side to increase placental blood flow.

C

Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency.

D

This is not a reassuring pattern, so the intravenous rate should be increased to increase the mothers blood volume.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 375-376

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. Which maternal condition is considered a contraindication for the application of internal monitoring devices?

a.

Unruptured membranes

b.

Cervix is dilated to 4 cm

c.

External monitors are currently being used

d.

Fetus has a known heart defect

ANS: A

Feedback

A

To apply internal monitoring devices, the membranes must be ruptured.

B

Cervical dilation of 4 cm permits the insertion of fetal scalp electrodes and intrauterine catheter.

C

The external monitor can be discontinued after the internal ones are applied.

D

A compromised fetus should be monitored with the most accurate monitoring devices.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 371

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

3. Which method of assessing the fetal heart rate requires the use of a gel?

a.

Fetoscope

b.

Tocodynamometer

c.

Doppler

d.

Scalp electrode

ANS: C

Feedback

A

The fetoscope does not require the use of gel because ultrasonic transmission is not used.

B

Tocodynamometer does not require the use of gel. This device monitors uterine contractions.

C

Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires use of a gel.

D

The scalp electrode is attached to the fetal scalp; gel is not necessary.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 370

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. How does the available staff influence the selection of either continuous electronic or intermittent auscultation as the fetal-monitoring method?

a.

There must be a 1:1 nurse-to-patient ratio regardless of the method used.

b.

Staffing patterns do not influence fetal monitoring choices.

c.

Use of intermittent auscultation requires a lower nurse-to-patient ratio.

d.

More nurses are needed when electronic fetal monitoring is used because of increased medical interventions.

ANS: C

Feedback

A

A one-to-one ratio is needed during the second stage of labor or if a high-risk condition exists, regardless of the monitoring method used.

B

Staffing patterns do plan a role in maintaining safe monitoring practice of the labor patient.

C

Intermittent auscultation is more staff-intensive.

D

Less nursing time is needed with electronic monitoring, giving the nurse more time for teaching and supporting the laboring woman.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 367

OBJ: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

5. The nurse knows that proper placement of the tocotransducer for electronic fetal monitoring is

a.

Over the uterine fundus

b.

On the fetal scalp

c.

Inside uterus

d.

Over the mothers lower abdomen

ANS: A

Feedback

A

The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur.

B

The tocotransducer monitors uterine contractions.

C

The tocotransducer is for external use.

D

The most intensive uterine contractions occur at the fundus; this is the best placement area.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 370

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

6. Perinatal nurses are legally responsible for

a.

Correctly interpreting FHR patterns, initiating appropriate nursing interventions, and documenting the outcomes

b.

Greeting the patient on arrival, assessing her, and starting an IV line

c.

Applying the external fetal monitor and notifying the care provider

d.

Making sure the woman is comfortable

ANS: A

Feedback

A

Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions.

B

These activities should be performed when any patient arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions.

C

This is a nursing function that is part of the standard of care for all obstetrical patients. This falls within the RN scope of practice.

D

Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 384-385

OBJ: Nursing Process: Assessment, Planning, and Implementation

MSC: Client Needs: Safe and Effective Care Environment

7. Which is the most appropriate method of intrapartum fetal monitoring when a woman has a history of hypertension during pregnancy?

a.

Continuous auscultation with a fetoscope

b.

Continuous electronic fetal monitoring

c.

Intermittent assessment with a Doppler transducer

d.

Intermittent electronic fetal monitoring for 15 minutes each hour

ANS: B

Feedback

A

It is not practical to provide continuous auscultation with a fetoscope.

B

Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition.

C

This fetus needs continuous monitoring because it is at high risk for complications.

D

This fetus needs continuous monitoring because it is at high risk for complications.

PTS: 1 DIF: Cognitive Level: Application REF: p. 366

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

8. Why is continuous electronic fetal monitoring usually used when oxytocin is administered?

a.

The mother may become hypotensive.

b.

Uteroplacental exchange may be compromised.

c.

Maternal fluid volume deficit may occur.

d.

Fetal chemoreceptors are stimulated.

ANS: B

Feedback

A

Hypotension is not a common side effect of oxytocin.

B

The uterus may contract more firmly, and the resting tone may be increased with oxytocin use. This response reduces entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves.

C

All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk.

D

Oxytocin affects the uterine muscles.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 366

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

9. The nurse-midwife is concerned that a womans uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. On the basis of this information, the nurse should obtain a(n)

a.

Tocotransducer

b.

Scalp electrode

c.

Intrauterine pressure catheter

d.

Doppler transducer

ANS: C

Feedback

A

The tocotransducer measures the uterine pressure externally; this not be accurate with obesity.

B

A scalp electrode measurers the fetal heart rate (FHR).

C

An intrauterine pressure catheter can measure actual intrauterine pressure.

D

A Doppler auscultates the FHR.

PTS: 1 DIF: Cognitive Level: Application REF: p. 371

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

10. In which situation is a baseline fetal heart rate of 160 to 170 beats per minute be considered a normal finding?

a.

The fetus is at 28 weeks of gestation.

b.

The mother has been given an epidural block.

c.

The mother has a history of fast labors.

d.

The mother has mild preeclampsia but is not in labor.

ANS: A

Feedback

A

The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR).

B

Any change in the FHR with an epidural is not considered an expected outcome.

C

Fast labors should not alter the FHR normally.

D

Preeclampsia should not cause a normal elevation of the FHR.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 372

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated?

a.

Administer oxygen by nasal cannula.

b.

Reposition the woman.

c.

Apply a fetal scalp electrode.

d.

Record this reassuring pattern.

ANS: D

Feedback

A

This is an early deceleration; it is reassuring.

B

This is an early deceleration; it is reassuring.

C

This is an early deceleration; it is reassuring.

D

The periodic pattern described is early deceleration that is not associated with fetal compromise and requires no intervention.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 373, 375

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. When the mothers membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?

a.

Increase in baseline variability

b.

Nonperiodic accelerations

c.

Early decelerations

d.

Variable decelerations

ANS: D

Feedback

A

This is not an expected occurrence after the rupture of membranes.

B

Accelerations are considered reassuring; they are not a concern after rupture of membranes.

C

Early declarations are considered reassuring; they are not a concern after rupture of membranes.

D

When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern.

PTS: 1 DIF: Cognitive Level: Application REF: p. 376

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

13. The fetal heart rate baseline increases 15 beats per minute after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing

a.

A reassuring response

b.

Progressive acidosis

c.

Parasympathetic stimulation

d.

A worsening hypoxia

ANS: A

Feedback

A

The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic stimulation with a temporary increase in the fetal heart rate (FHR) over baseline of 15 bpm for 15 seconds or more.

B

An increase in the FHR after stimulation is reassuring.

C

An increase in the FHR after stimulation is a reassuring pattern and does not indicate problems with the parasympathetic nervous system.

D

An increase in the FHR with stimulation does not indicate hypoxia.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 377

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

14. When a nonreassuring pattern of the fetal heart rate is noted and the mother is lying on her left side, what nursing action is indicated?

a.

Lower the head of the bed.

b.

Place the mother in a Trendelenburg position.

c.

Change her position to the right side.

d.

Place a wedge under the left hip.

ANS: C

Feedback

A

Repositioning to the opposite side is the first intervention. If unsuccessful with improving the FHR pattern, further changes in position can be attempted.

B

The Trendelenburg position is not appropriate for early interventions. If unsuccessful with improving the FHR pattern with other types of position changes, Trendelenburg may be the choice.

C

Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta.

D

The woman is already on her left side, so a wedge on that side is not an appropriate choice.

PTS: 1 DIF: Cognitive Level: Application REF: p. 377

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

15. The nurse notes a pattern of late decelerations on the fetal monitor. The most appropriate action is to

a.

Continue observation of this reassuring pattern.

b.

Notify the physician or nurse-midwife.

c.

Give the woman oxygen by face mask.

d.

Place the woman in a Trendelenburg position.

ANS: C

Feedback

A

This is not a reassuring pattern; interventions are needed.

B

Nursing interventions should be initiated before notifying the health care provider.

C

Late decelerations are associated with reduced placental perfusion. Giving the laboring woman oxygen increases the oxygen saturation in her blood, making more oxygen available to the fetus.

D

The Trendelenburg position will not increase the placental perfusion.

PTS: 1 DIF: Cognitive Level: Application REF: p. 380

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by

a.

Maintaining normal maternal temperature

b.

Preventing normal maternal hypoglycemia

c.

Increasing the oxygen-carrying capacity of the maternal blood

d.

Expanding maternal blood volume

ANS: D

Feedback

A

Increasing fluid volume may alter the maternal temperature only if she is dehydrated.

B

Most intravenous fluids for laboring women are isotonic and do not add extra glucose.

C

Oxygen-carrying capacity is increased by adding more red blood cells.

D

Filling the mothers vascular system makes more blood available to perfuse the placenta and may correct hypotension.

PTS: 1 DIF: Cognitive Level: Application REF: p. 380

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

17. Which nursing action is correct when initiating electronic fetal monitoring?

a.

Lubricate the tocotransducer with an ultrasound gel.

b.

Inform the patient that she should remain in the semi-Fowlers position.

c.

Securely apply the tocotransducer with a strap or belt.

d.

Determine the position of the fetus before attaching the electrode to the maternal abdomen.

ANS: C

Feedback

A

The tocotransducer does not need gel to operate appropriately.

B

The patient should be encouraged to move around during labor.

C

The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately.

D

The tocotransducer should be placed at the fundal area of the uterus.

PTS: 1 DIF: Cognitive Level: Application REF: p. 370

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

18. Which statement correctly describes the nurses responsibility related to electronic monitoring?

a.

Teach the woman and her support person about the monitoring equipment and discuss any questions they have.

b.

Report abnormal findings to the physician before initiating corrective actions.

c.

Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place.

d.

Document the frequency, duration, and intensity of contractions measured by the external device.

ANS: A

Feedback

A

Teaching is an essential part of the nurses role.

B

Corrective actions should be initiated first in order to correct abnormal findings as quickly as possible.

C

The support person should still be encouraged to assist with the comfort measures.

D

Electronic monitoring will record the contractions and FHR response.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 382-383

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

19. When using IA for FHR, nurses should be aware that

a.

They can be expected to cover only two or three patients when IA is the primary method of fetal assessment.

b.

The best course is to use the descriptive terms associated with EFM when documenting results.

c.

If the heartbeat cannot be found immediately, a shift must be made to electronic monitoring.

d.

Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.

ANS: D

Feedback

A

When used as the primary method of fetal assessment, auscultation requires a nurse-to-patient ratio of one to one.

B

Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate.

C

Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if that device is used to help locate the heartbeat.

D

Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if that device is used to help locate the heartbeat.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 367

OBJ: Nursing Process: Assessment and Planning

MSC: Client Needs: Health Promotion and Maintenance

20. The nurse caring for the woman in labor should understand that absent or minimal variability is classified as either abnormal or indeterminate. Which condition related to decreased variability is considered benign?

a.

A periodic fetal sleep state

b.

Extreme prematurity

c.

Fetal hypoxemia

d.

Pre-existing neurologic injury

ANS: A

Feedback

A

When the fetus is temporarily in a sleep state there is minimal variability present. Periodic fetal sleep states usually last no longer than 30 minutes.

B

A woman who presents in labor with extreme prematurity may display a FHR pattern of minimal or absent variability.

C

Abnormal variability may also be related to fetal hypoxemia and metabolic acidemia.

D

Congenital anomalies or pre-existing neurologic injury may also present as absent or minimal variability. Other possible causes might be CNS depressant medications, narcotics or general anesthesia.

O

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 372

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

21. A nurse might be called on to stimulate the fetal scalp

a.

As part of fetal scalp blood sampling

b.

In response to tocolysis

c.

In preparation for fetal oxygen saturation monitoring

d.

To elicit an acceleration in the FHR

ANS: D

Feedback

A

Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse would stimulate the fetal scalp to elicit an acceleration of the FHR.

B

Tocolysis is relaxation of the uterus. The nurse would stimulate the fetal scalp to elicit an acceleration of the FHR.

C

Fetal oxygen saturation monitoring involves the insertion of a sensor. The nurse would stimulate the fetal scalp to elicit an acceleration of the FHR.

D

The scalp can be stimulated using digital pressure during a vaginal examination.

PTS: 1 DIF: Cognitive Level: Application REF: p. 379

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

22. An important part of fetal surveillance is assessment and documentation of the fetal heart rate during the first stage of labor. In the low-risk patient assessments for variability and periodic changes if using the fetal monitor should be done

a.

Every 15-30 minutes

b.

Every 5-15 minutes

c.

Every 30-60 minutes

d.

Only before and after ambulation

ANS: A

Feedback

A

During the active first stage of labor, FHR should be assessed every 15-30 minutes just after a contraction.

B

During the second stage of labor the FHR should be assessed every 5-15 minutes.

C

This is not an adequate assessment during any stage of labor.

D

The FHR should also be evaluated both before and during ambulation.

PTS: 1 DIF: Cognitive Level: Application REF: p. 385 | Box 17-2

OBJ: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

MULTIPLE RESPONSE

1. Labor is very stressful for the fetus. It is important for the intrapartum nurse to be knowledgeable regarding the mechanisms that regulate the fetal heart rate and keep the brain well oxygenated. When evaluating the patients progress, the nurse knows that four of the five fetal factors that interact to regulate the heart rate are the

a.

Uterine activity

b.

Autonomic nervous system

c.

Baroreceptors

d.

Chemoreceptors

e.

Adrenal glands

ANS: B, C, D, E

Feedback

Correct

The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, while parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and the aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing an acceleration in FHR.

Incorrect

Hypertonic uterine activity can reduce the time available for exchange of oxygen and waste products; however, this is a maternal factor. The fifth fetal factor is the central nervous system. The fetal cerebral cortex causes the heart rate to increase during fetal movement and decrease when the fetus sleeps.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 365

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

2. The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patients most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration? Select all that apply.

a.

Spontaneous fetal movement

b.

Compression of the fetal head

c.

Placental abruption

d.

Cord around the babys neck

e.

Maternal supine hypotension

ANS: C, E

Feedback

Correct

Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by: uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption.

Incorrect

Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination and placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the cord is around the babys neck, arm, leg or other body part, a short cord, a knot in the cord or a prolapsed cord.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 375

OBJ: Nursing Process: Assessment and Diagnosis

MSC: Client Needs: Physiologic Integrity

3. According to the NICHD Three-Tier System of Fetal Heart Rate Classification, Category III tracings include all FHR tracings not categorized as Category I or II. Which characteristics of the fetal heart belong in Category III? Select all that apply.

a.

Baseline rate of 110 to 160 bpm

b.

Tachycardia

c.

Absent baseline variability NOT accompanied by recurrent decelerations

d.

Variable decelerations with other characteristics such as shoulders or overshoots

e.

Absent baseline variability with recurrent variable decelerations

f.

Bradycardia

ANS: B, D, E, F

Feedback

Correct

These characteristics are all considered non-reassuring or abnormal and belong in Category III.

Incorrect

A fetal heart rate of 110 to 160 bpm is considered normal and belongs in Category I. Absent baseline variability not accompanied by recurrent decelerations is a Category II characteristic.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 377

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

COMPLETION

1. The labor and delivery nurse is using a well-known method to quantify the intensity of labor contractions with internal monitoring. This method is known as MVUs, or ______________.

ANS:

Montevideo units

The baseline intrauterine pressure for each contraction within a 10-minute period is subtracted from the peak pressure. The resulting pressures (peak subtract baseline) are added together to calculate the Montevideo units.

PTS: 1 DIF: Cognitive Level: Application REF: p. 376

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

TRUE/FALSE

1. According to the 2008 National Institute of Child Health and Human Development (NICHD) nomenclature, there are four categories of fetal heart rate variability: absent, minimal, moderate, and marked. Is this statement true or false?

ANS: T

Absent: the amplitude range is undetectable. Minimal: detectable to less than or equal to 5 bpm. Moderate (normal): 6 to 25 bpm. Marked: a range greater than 25 bpm.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 373

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

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