Chapter 18: Fetal Assessment During Labor My Nursing Test Banks

Chapter 18: Fetal Assessment During Labor

Lowdermilk: Maternity & Womens Health Care, 11th Edition

MULTIPLE CHOICE

1. What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?

a.

Altered fetal cerebral blood flow

b.

Umbilical cord compression

c.

Uteroplacental insufficiency

d.

Spontaneous rupture of membranes

ANS: A

Early decelerations are the fetus response to fetal head compression; these are considered benign, and interventions are not necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

DIF: Cognitive Level: Understand REF: p. 410

TOP: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance

2. Which clinical finding or intervention might be considered the rationale for fetal tachycardia to occur?

a.

Maternal fever

b.

Umbilical cord prolapse

c.

Regional anesthesia

d.

Magnesium sulfate administration

ANS: A

Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. Umbilical cord prolapse, regional anesthesia, and the administration of magnesium sulfate will each more likely result in fetal bradycardia, not tachycardia.

DIF: Cognitive Level: Understand REF: p. 419

TOP: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance

3. While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the FHR for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. What is the nurses first priority?

a.

Change the womans position.

b.

Notify the health care provider.

c.

Assist with amnioinfusion

d.

Insert a scalp electrode.

ANS: A

Late FHR decelerations may be caused by maternal supine hypotension syndrome. These decelerations are usually corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, then the nurse should continue with subsequent intrauterine resuscitation measures and notify the health care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely will reveal variable decelerations. Although a fetal scalp electrode will provide accurate data for evaluating the well-being of the fetus, it is not a nursing intervention that will alleviate late decelerations nor is it the nurses first priority.

DIF: Cognitive Level: Apply REF: p. 422

TOP: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance

4. What is the most likely cause for variable FHR decelerations?

a.

Altered fetal cerebral blood flow

b.

Umbilical cord compression

c.

Uteroplacental insufficiency

d.

Fetal hypoxemia

ANS: B

Variable FHR decelerations can occur at any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in the FHR. Fetal hypoxemia initially results in tachycardia and then bradycardia if hypoxia continues.

DIF: Cognitive Level: Remember REF: p. 422

TOP: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance

5. The nurse providing care for a high-risk laboring woman is alert for late FHR decelerations. Which clinical finding might be the cause for these late decelerations?

a.

Altered cerebral blood flow

b.

Umbilical cord compression

c.

Uteroplacental insufficiency

d.

Meconium fluid

ANS: C

Uteroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood flow results in early FHR decelerations. Umbilical cord compression results in variable FHR decelerations. Meconium-stained fluid may or may not produce changes in the FHR, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.

DIF: Cognitive Level: Understand REF: p. 421

TOP: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance

6. Which alteration in the FHR pattern would indicate the potential need for an amnioinfusion?

a.

Variable decelerations

b.

Late decelerations

c.

Fetal bradycardia

d.

Fetal tachycardia

ANS: A

Amnioinfusion is used during labor to either dilute meconium-stained amniotic fluid or supplement the amount of amniotic fluid to reduce the severity of variable FHR decelerations caused by cord compression. Late decelerations are unresponsive to amnioinfusion. Amnioinfusion is not appropriate for the treatment of fetal bradycardia and has no bearing on fetal tachycardia.

DIF: Cognitive Level: Remember REF: p. 425

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

7. Which FHR finding is the most concerning to the nurse who is providing care to a laboring client?

a.

Accelerations with fetal movement

b.

Early decelerations

c.

Average FHR of 126 beats per minute

d.

Late decelerations

ANS: D

Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. Late FHR decelerations are considered ominous if they are persistent and left uncorrected. Accelerations with fetal movement are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they are not generally a concern during normal labor. An FHR finding of 126 beats per minute is normal and not a concern.

DIF: Cognitive Level: Analyze REF: p. 421

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

8. What three measures should the nurse implement to provide intrauterine resuscitation?

a.

Call the provider, reposition the mother, and perform a vaginal examination.

b.

Turn the client onto her side, provide oxygen (O2) via face mask, and increase intravenous (IV) fluids.

c.

Administer O2 to the mother, increase IV fluids, and notify the health care provider.

d.

Perform a vaginal examination, reposition the mother, and provide O2 via face mask.

ANS: B

Basic interventions for the management of any abnormal FHR pattern include administering O2 via a nonrebreather face mask at a rate of 8 to 10 L/min, assisting the woman onto a side-lying (lateral) position, and increasing blood volume by increasing the rate of the primary IV infusion. The purpose of these interventions is to improve uterine blood flow and intervillous space blood flow and to increase maternal oxygenation and cardiac output. The term intrauterine resuscitation is sometimes used to refer to these interventions. If these interventions do not quickly resolve the abnormal FHR issue, then the primary provider should be immediately notified.

DIF: Cognitive Level: Analyze REF: p. 425

TOP: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance, Physiologic Integrity

9. The nurse who provides care to clients in labor must have a thorough understanding of the physiologic processes of maternal hypotension. Which outcome might occur if the interventions for maternal hypotension are inadequate?

a.

Early FHR decelerations

b.

Fetal arrhythmias

c.

Uteroplacental insufficiency

d.

Spontaneous rupture of membranes

ANS: C

Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early FHR decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.

DIF: Cognitive Level: Understand REF: p. 421

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

10. What are the legal responsibilities of the perinatal nurses?

a.

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

b.

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

c.

Applying the external fetal monitor and notifying the health care provider

d.

Ensuring that the woman is comfortable

ANS: 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. Greeting the client on arrival, assessing her, and starting an IV line are activities that should be performed when any client arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions. Applying the external fetal monitor and notifying the health care provider is a nursing function that is part of the standard of care for all obstetric clients and falls within the registered nurses scope of practice. Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable.

DIF: Cognitive Level: Understand REF: p. 424

TOP: Nursing Process: Assessment | Nursing Process: Planning | Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

11. The perinatal nurse realizes that an FHR that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with which condition?

a.

Hypotension

b.

Cord compression

c.

Maternal drug use

d.

Hypoxemia

ANS: D

Nonreassuring FHR patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Variable FHR decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.

DIF: Cognitive Level: Analyze REF: p. 411

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

12. A new client and her partner arrive on the labor, delivery, recovery, and postpartum (LDRP) unit for the birth of their first child. The nurse applies the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the babys heart rate should be. What is the nurses best response?

a.

Dont worry about that machine; thats my job.

b.

The babys heart rate will fluctuate in response to what is happening during labor.

c.

The top line graphs the babys heart rate, and the bottom line lets me know how strong the contractions are.

d.

Your physician will explain all of that later.

ANS: B

Explaining what indicates a normal FHR teaches the partner about fetal monitoring and provides support and information to alleviate his fears. Telling the partner not to worry discredits his feelings and does not provide the teaching he is requesting. Telling the partner that the graph indicates how strong the contractions are provides inaccurate information and does not address the partners concerns about the FHR. The EFM graphs the frequency and duration of the contractions, not their intensity. Nurses should take every opportunity to provide teaching to the client and her family, especially when information is requested.

DIF: Cognitive Level: Apply REF: p. 417 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

13. Which statement best describes a normal uterine activity pattern in labor?

a.

Contractions every 2 to 5 minutes

b.

Contractions lasting approximately 2 minutes

c.

Contractions approximately 1 minute apart

d.

Contraction intensity of approximately 500 mm Hg with relaxation at 50 mm Hg

ANS: A

Overall contraction frequency generally ranges from two to five contractions per 10 minutes of labor, with lower frequencies during the first stage and higher frequencies observed during the second stage. Contraction duration remains fairly stable throughout the first and second stages, ranging from 45 to 80 seconds, generally not exceeding 90 seconds. Contractions 1 minute apart are occurring too often and would be considered an abnormal labor pattern. The intensity of uterine contractions generally ranges from 25 to 50 mm Hg in the first stage of labor and may rise to more than 80 mm Hg in the second stage.

DIF: Cognitive Level: Remember REF: p. 411

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

14. The nurse is using intermittent auscultation (IA) to locate the fetal heartbeat. Which statement regarding this method of surveillance is accurate?

a.

The nurse can be expected to cover only two or three clients 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 immediately found, then a shift must be made to EFM.

d.

Ultrasound can be used to find the FHR and to reassure the mother if the initial difficulty is a factor.

ANS: D

Locating fetal heartbeats often takes time. Mothers can be verbally reassured and reassured by viewing the ultrasound pictures if that device is used to help locate the heartbeat. When used as the primary method of fetal assessment, IA requires a nurse-to-client ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate.

DIF: Cognitive Level: Understand REF: p. 413

TOP: Nursing Process: Assessment | Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

15. What is a distinct advantage of external EFM?

a.

The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the FHR.

b.

The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions.

c.

The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor.

d.

Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.

ANS: C

The tocotransducer is valuable for measuring uterine activity during the first stage of labor and is especially true when the membranes are intact. Short-term variability and beat-to-beat changes cannot be measured with this technology. The tocotransducer cannot measure and record the intensity of uterine contractions. The transducer must be repositioned when the woman or the fetus changes position.

DIF: Cognitive Level: Understand REF: pp. 414-415

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

16. Which client would not be a suitable candidate for internal EFM?

a.

Client who still has intact membranes

b.

Woman whose fetus is well engaged in the pelvis

c.

Pregnant woman who has a comorbidity of obesity

d.

Client whose cervix is dilated to 4 to 5 cm

ANS: A

For internal EFM, the membranes must have ruptured and the cervix must be dilated at least 2 to 3 cm. The presenting part must be low enough to allow placement of the spiral electrode necessary for internal EFM. The accuracy of EFM is not affected by maternal size. However, evaluating fetal well-being using external EFM may be more difficult on an obese client. The client whose cervix is dilated to 4 to 5 cm is indeed a candidate for internal monitoring.

DIF: Cognitive Level: Understand REF: p. 416 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

17. During labor a fetus displays an average FHR of 135 beats per minute over a 10-minute period. Which statement best describes the status of this fetus?

a.

Bradycardia

b.

Normal baseline heart rate

c.

Tachycardia

d.

Hypoxia

ANS: B

The baseline FHR is measured over 10 minutes; a normal range is 110 to 160 beats per minute. Bradycardia is a FHR less than 110 beats per minute for 10 minutes or longer. Tachycardia is a FHR higher than 160 beats per minutes for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of hypoxia exists with a baseline FHR in the normal range.

DIF: Cognitive Level: Remember REF: p. 411

TOP: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance, Physiologic Integrity

18. A nurse caring for a 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.

Periodic fetal sleep state

b.

Extreme prematurity

c.

Fetal hypoxemia

d.

Preexisting neurologic injury

ANS: A

When the fetus is temporarily in a sleep state, minimal variability is present. Periodic fetal sleep states usually last no longer than 30 minutes. A woman in labor with extreme prematurity may display a FHR pattern of minimal or absent variability. Abnormal variability may also be related to fetal hypoxemia and metabolic acidemia. Congenital anomalies or a preexisting neurologic injury may also result in absent or minimal variability. Other possible causes might be central nervous system (CNS) depressant medications, narcotics, or general anesthesia.

DIF: Cognitive Level: Understand REF: p. 418

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

19. Which definition of an acceleration in the fetal heart rate (FHR) is accurate?

a.

FHR accelerations are indications of fetal well-being when they are periodic.

b.

FHR accelerations are greater and longer in preterm gestations.

c.

FHR accelerations are usually observed with breech presentations when they are episodic.

d.

An acceleration in the FHR presents a visually apparent and abrupt peak.

ANS: D

Acceleration of the FHR is defined as a visually apparent abrupt (only to peak 30 seconds) increase in the FHR above the baseline rate. Periodic accelerations occur with uterine contractions and are usually observed with breech presentations. Episodic accelerations occur during fetal movement and are indications of fetal well-being. Preterm accelerations peak at 10 beats per minute above the baseline and last for at least 10 seconds.

DIF: Cognitive Level: Remember REF: p. 420

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

20. Which characteristic correctly matches the type of deceleration with its likely cause?

a.

Early decelerationumbilical cord compression

b.

Late decelerationuteroplacental insufficiency

c.

Variable decelerationhead compression

d.

Prolonged decelerationunknown cause

ANS: B

Late deceleration is caused by uteroplacental insufficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

DIF: Cognitive Level: Remember REF: pp. 420-421

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

21. Which information related to a prolonged deceleration is important for the labor nurse to understand?

a.

Prolonged decelerations present a continuing pattern of benign decelerations that do not require intervention.

b.

Prolonged decelerations constitute a baseline change when they last longer than 5 minutes.

c.

A disruption to the fetal oxygen supply causes prolonged decelerations.

d.

Prolonged decelerations require the customary fetal monitoring by the nurse.

ANS: C

Prolonged decelerations are caused by a disruption in the fetal oxygen supply. They usually begin as a reflex response to hypoxia. If the disruption continues, then the fetal cardiac tissue, itself, will become hypoxic, resulting in direct myocardial depression of the FHR. Prolonged decelerations can be caused by prolonged cord compression, uteroplacental insufficiency, or perhaps sustained head compression. Prolonged decelerations lasting longer than 10 minutes are considered a baseline change that may require intervention. A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in the FHR of at least 15 beats per minute below the baseline and lasting longer than 2 minutes but shorter than 10 minutes. Nurses should immediately notify the physician or nurse-midwife and initiate appropriate treatment of abnormal patterns when they see prolonged decelerations.

DIF: Cognitive Level: Understand REF: p. 422

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

22. In which situation would the nurse 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

The scalp can be stimulated using digital pressure during a vaginal examination. Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse stimulates the fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxation of the uterus. Fetal oxygen saturation monitoring involves the insertion of a sensor.

DIF: Cognitive Level: Apply REF: p. 425

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

23. Part of the nurses role is assisting with pushing and positioning. Which guidance should the nurse provide to her client in active labor?

a.

Encourage the womans cooperation in avoiding the supine position.

b.

Advise the woman to avoid the semi-Fowler position.

c.

Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response.

d.

Instruct the woman to open her mouth and close her glottis, letting air escape after the push.

ANS: A

The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. Encouraging the woman to hold her breath and tighten her abdominal muscles is the Valsalva maneuver, which should be avoided. Both the mouth and glottis should be open, allowing air to escape during the push.

DIF: Cognitive Level: Apply REF: p. 427

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

24. In which clinical situation would the nurse most likely anticipate a fetal bradycardia?

a.

Intraamniotic infection

b.

Fetal anemia

c.

Prolonged umbilical cord compression

d.

Tocolytic treatment using terbutaline

ANS: C

Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

DIF: Cognitive Level: Understand REF: p. 422

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

25. Which nursing intervention would result in an increase in maternal cardiac output?

a.

Change in position

b.

Oxytocin administration

c.

Regional anesthesia

d.

IV analgesic

ANS: A

Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This position reduces venous return to the womans heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and to avoid the supine position. Oxytocin administration, regional anesthesia, and IV analgesic may reduce maternal cardiac output.

DIF: Cognitive Level: Apply REF: p. 425

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

26. The nurse is evaluating the EFM tracing of the client who is in active labor. Suddenly, the FHR drops from its baseline of 125 down to 80 beats per minute. The mother is repositioned, and the nurse provides oxygen, increased IV fluids, and performs a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take next?

a.

Call for help.

b.

Insert a Foley catheter.

c.

Start administering Pitocin.

d.

Immediately notify the care provider.

ANS: D

To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluids, and provide oxygen. If oxytocin is infusing, then it should be discontinued. If the FHR does not resolve, then the primary care provider should be immediately notified. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, then a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. The administration of Pitocin may place additional stress on the fetus.

DIF: Cognitive Level: Analyze REF: p. 425

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

27. The nurse observes a sudden increase in variability on the ERM tracing. Which class of medications may cause this finding?

a.

Narcotics

b.

Barbiturates

c.

Methamphetamines

d.

Tranquilizers

ANS: C

Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; whereas methamphetamines may cause increased variability.

DIF: Cognitive Level: Understand REF: p. 419

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

28. What is the correct placement of the tocotransducer for effective EFM?

a.

Over the uterine fundus

b.

On the fetal scalp

c.

Inside the uterus

d.

Over the mothers lower abdomen

ANS: A

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

DIF: Cognitive Level: Understand REF: p. 414

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

29. What physiologic change occurs as the result of increasing the infusion rate of nonadditive IV fluids?

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

Filling the mothers vascular system increases the amount of blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

DIF: Cognitive Level: Apply REF: p. 425

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

30. The client has delivered by urgent caesarean birth for fetal compromise. Umbilical cord gases were obtained for acid-base determination. The pH is 6.9, partial pressure of carbon dioxide (PCO2) is elevated, and the base deficit is 11 mmol/L. What type of acidemia is displayed by the infant?

a.

Respiratory

b.

Metabolic

c.

Mixed

d.

Turbulent

ANS: A

These findings are evidence of respiratory acidemia. Metabolic acidemia is expressed by a pH <7.20, normal carbon dioxide pressure, and a base excess of 12 mmol/L. Mixed acidemia is evidenced by a pH <7.20, elevated carbon dioxide pressure, and a base excess of 12 mmol/L. There is no such finding as turbulent acidemia.

DIF: Cognitive Level: Analyze REF: p. 426

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

MULTIPLE RESPONSE

1. In assessing the immediate condition of the newborn after birth, a sample of cord blood may be a useful adjunct to the Apgar score. Cord blood is then tested for pH, carbon dioxide, oxygen, and base deficit or excess. Which clinical situation warrants this additional testing? (Select all that apply.)

a.

Low 5-minute Apgar score

b.

Intrauterine growth restriction (IUGR)

c.

Maternal thyroid disease

d.

Intrapartum fever

e.

Vacuum extraction

ANS: A, B, C, D

The American College of Obstetricians and Gynecologists (ACOG) suggests obtaining cord blood values in all of these clinical situations except for vacuum extractions deliveries. Cord blood gases should also be performed for multifetal pregnancies or abnormal FHR tracings. Samples can be drawn from both the umbilical artery and the umbilical vein. Results may indicate that fetal compromise has occurred.

DIF: Cognitive Level: Understand REF: p. 426

TOP: Nursing Process: Planning | Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

2. According to the National Institute of Child Health and Human Development (NICHD) Three-Tier System of FHR Classification, category III tracings include all FHR tracings not categorized as category I or II. Which characteristics of the FHR belong in category III? (Select all that apply.)

a.

Baseline rate of 110 to 160 beats per minute

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

Tachycardia, variable decelerations with other characteristics, absent baseline variability with recurrent variable decelerations, and bradycardia are characteristics that are considered nonreassuring or abnormal and belong in category III. A FHR of 110 to 160 beats per minute is considered normal and belongs in category I. Absent baseline variability not accompanied by recurrent decelerations is a category II characteristic.

DIF: Cognitive Level: Analyze REF: p. 411 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

3. Which FHR decelerations would require the nurse to change the maternal position? (Select all that apply.)

a.

Early decelerations

b.

Late decelerations

c.

Variable decelerations

d.

Moderate decelerations

e.

Prolonged decelerations

ANS: B, C, E

Early decelerations (and accelerations) do not generally need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral). Variable decelerations also require a maternal position change (side to side). Moderate decelerations are not an accepted category. Prolonged decelerations are late or variable decelerations that last for a prolonged period (longer than 2 minutes) and require intervention.

DIF: Cognitive Level: Understand REF: pp. 422, 423

TOP: Nursing Process: Assessment | Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

4. A tiered system of categorizing FHR has been recommended by professional organizations. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. What is the correct nomenclature for these categories? (Select all that apply.)

a.

Reassuring

b.

Category I

c.

Category II

d.

Nonreassuring

e.

Category III

ANS: B, C, E

The three-tiered system of FHR tracings include category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate and includes tracings that do not meet category I or III criteria. Category III tracings are abnormal and require immediate intervention.

DIF: Cognitive Level: Understand REF: p. 411

TOP: Nursing Process: Assessment | Nursing Process: Planning

MSC: Client Needs: Physiologic Integrity

5. The baseline 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 clients most recent 10-minute segment on the monitor strip and notes a late deceleration. Which is likely to have caused this change? (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

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. 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 the placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression, which may happen when the umbilical cord is around the babys neck, arm, leg, or other body part or when a short cord, a knot in the cord, or a prolapsed cord is present.

DIF: Cognitive Level: Analyze REF: p. 422

TOP: Nursing Process: Assessment | Nursing Process: Diagnosis

MSC: Client Needs: Physiologic Integrity

MATCHING

Fetal well-being in labor can be measured by the response of the FHR to uterine contractions. Match the characteristic of normal uterine activity during labor with the correct description.

a.

Frequency

b.

Duration

c.

Strength

d.

Resting tone

e.

Relaxation time

1. Commonly 45 seconds or more in the second stage of labor

2. Generally ranging from two to five contractions per 10 minutes of labor

3. Average of 10 mm Hg

4. Peaking at 40 to 70 mm Hg in the first stage of labor

5. Remaining fairly stable throughout the first and second stages

1. ANS: E DIF: Cognitive Level: Analyze REF: p. 411

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

NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage.

2. ANS: A DIF: Cognitive Level: Analyze REF: p. 411

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

NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage.

3. ANS: D DIF: Cognitive Level: Analyze REF: p. 411

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

NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage.

4. ANS: C DIF: Cognitive Level: Analyze REF: p. 411

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

NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage.

5. ANS: B DIF: Cognitive Level: Analyze REF: p. 411

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

NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage.

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