Chapter 21 Intrapartum Nursing Assessment My Nursing Test Banks

Olds Maternal-Newborn Nursing and Womens Health, 10e (Davidson)

Chapter 21 Intrapartum Nursing Assessment

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

1. How did you decide to have your baby at this hospital?

2. Who will be your labor support person?

3. Have you chosen names for your baby yet?

4. What feeding method will you use for your baby?

Answer: 2

Explanation: 2. The expectant mothers partner or support person is an important member of the birthing team, and assessments of the couples coping, interactions, and teamwork are integral to the nurses knowledge base. The nurses physical presence with the laboring woman provides the best opportunity for ongoing assessment.

Page Ref: 469

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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

1. Blood pressure 120/88

2. Father a carrier of sickle-cell trait

3. Dark red vaginal bleeding

4. History of domestic abuse

Answer: 3

Explanation: 3. Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus.

Page Ref: 473

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

3) The nurse is working with a pregnant adolescent. The client asks the nurse how the babys condition is determined during labor. The nurses best response is that during labor, the nurse will do which of the following?

1. Check the clients cervix by doing a pelvic exam every 2 hours.

2. Assess the fetuss heart rate with an electronic fetal monitor.

3. Look at the color and amount of bloody show that the client has.

4. Verify that the clients contractions are strong but not too close together.

Answer: 2

Explanation: 2. This statement best answers the question the client has asked.

Page Ref: 480

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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4) During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The clients partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Uterine contraction pattern

2. Fetal position

3. Presence of the mucous plug

4. Cervical dilation and effacement

5. Presenting part

Answer: 4, 5

Explanation: 4. The vaginal examination of a laboring client obtains information about the station of the presenting part and the dilation and effacement of the cervix.

5. The vaginal examination of a laboring client obtains information about the fetal presenting part.

Page Ref: 483

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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5) A client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Check for ruptured membranes and apply a fetal scalp electrode.

2. Auscultate the fetal heart rate between and during contractions.

3. Palpate contractions and resting uterine tone.

4. Assess the blood pressure, temperature, respiratory rate, and pulse rate.

5. Perform a vaginal exam for cervical dilation, and perform Leopold maneuvers.

Answer: 2, 3

Explanation: 2. Fetal heart rate auscultation gives information about the physical status of the fetus.

3. Contraction palpation provides information about the frequency, duration, and intensity of the contractions.

Page Ref: 481, 487

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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6) The nurse is preparing to assess a laboring client who has just arrived in the labor and birth unit. Which statement by the client indicates that additional education is needed?

1. You are going to do a vaginal exam to see how dilated my cervix is.

2. The reason for a pelvic exam is to determine how low in the pelvis my baby is.

3. When you check my cervix, you will find out how thinned out it is.

4. After you assess my pelvis, you will be able to tell when I will deliver.

Answer: 4

Explanation: 4. An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic exam, no information is obtained about contractions. The nurse will not have enough information following the cervical exam to estimate time of birth.

Page Ref: 483

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care measures. | AACN Essentials Competencies: IX: 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

7) The client has been pushing for 3 hours, and the fetus is making a slow descent. The partner asks the nurse whether pushing for this long is normal. How should the nurse respond?

1. Your baby is taking a little longer than average, but is making progress.

2. First babies take a long time to be born. The next baby will be easier.

3. The birth would go faster if you had taken prenatal classes and practiced.

4. Every baby is different; there really are no norms for labor and birth.

Answer: 1

Explanation: 1. Establishing rapport and a trusting relationship and providing information that is true is best response.

Page Ref: 479

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments ne

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cessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

8) During a maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in what quadrant?

1. Right upper quadrant

2. Left upper quadrant

3. Right lower quadrant

4. Left lower quadrant

Answer: 4

Explanation: 4. The fetal heart rate (FHR) is heard most clearly at the fetal back. Thus, in a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen.

Page Ref: 487

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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9) A laboring client asks the nurse, Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor? The nurse would accurately explain that the best rationale for using an IUPC is which of the following?

1. The IUPC can be used throughout the birth process.

2. A tocodynamometer is invasive.

3. The IUPC provides more accurate data than does the tocodynamometer.

4. The tocodynamometer can be used only after the cervix is dilated 2 cm.

Answer: 3

Explanation: 3. The IUPC has several benefits over an external tocotransducer or palpation. Because the IUPC is inserted directly into the uterus, it provides near-exact pressure measurements for contraction intensity and uterine resting tone. The increased sensitivity of the IUPC allows for very accurate timing of uterine contractions (UCs).

Page Ref: 483

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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

1. Woman at 7 cm, fetal heart tones auscultated every 90 minutes

2. Woman at 10 cm and pushing, external fetal monitor applied

3. Woman with meconium-stained fluid, internal fetal scalp electrode in use

4. Woman in preterm labor, external monitor in place

Answer: 1

Explanation: 1. During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough.

Page Ref: 480

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions,

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giving advantages and disadvantages of each.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

11) 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?

1. The monitor is necessary so we can see how your labor is progressing.

2. The monitor will prevent complications from the meconium in your fluid.

3. The monitor helps us to see how the baby is tolerating labor.

4. The monitor can be removed, and oxygen given instead.

Answer: 3

Explanation: 3. Electronic fetal monitoring (EFM) provides a continuous tracing of the fetal heart rate (FHR), allowing characteristics of the FHR to be observed and evaluated.

Page Ref: 489

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively: listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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

1. Mild

2. Moderate

3. Strong

4. Weak

Answer: 3

Explanation: 3. The consistency of strong contractions is similar to that of the forehead.

Page Ref: 481

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

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MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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13) 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.

Select all that apply.

1. Have the client empty her bladder.

2. Place the client in Trendelenburg position.

3. Have the client lie on her back with her feet on the bed and knees bent.

4. Turn the client to her left side.

5. Have the client lie flat with her ankles crossed.

Answer: 1, 3

Explanation: 1. The woman should have recently emptied her bladder before performing Leopold maneuvers.

3. The woman should lie on her back with her abdomen uncovered. To aid in relaxation of the abdominal wall, the shoulders should be raised slightly on a pillow and the knees drawn up a little.

Page Ref: 485

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information that can be obtained.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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

1. The client is assisted into supine position, and the position of the fetus is assessed.

2. The upper portion of the uterus is palpated, then the middle section.

3. After determining where the back is located, the cervix is assessed.

4. Following voiding, the clients abdomen is palpated from top to bottom.

Answer: 3

Explanation: 3. The cervical exam is not part of Leopold maneuvers. Abdominal palpation is the only technique used for Leopold maneuvers.

Page Ref: 485, 486

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families and the health care team. | AACN Essentials Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information that can be obtained.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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

1. Perform Leopold maneuvers to determine fetal position.

2. Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (UC).

3. Dry the maternal abdomen before using the Doppler.

4. The diaphragm should be cooled before using the Doppler.

Answer: 1

Explanation: 1. Performing Leopold maneuvers is the first step.

Page Ref: 485, 486

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information that can be obtained.

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MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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

1. Breech presentation

2. Uteroplacental insufficiency

3. Compression of the fetal head

4. Umbilical cord compression

Answer: 4

Explanation: 4. Variable decelerations occur when there is umbilical cord compression.

Page Ref: 501

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

17) The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate?

1. Inform the maternal client that the rate is normal.

2. Reassess the FHR in 5 minutes because the rate is low.

3. Report the FHR to the doctor immediately.

4. Turn the maternal client on her side and administer oxygen.

Answer: 1

Explanation: 1. A fetal heart rate of 112 beats/min. falls within the normal range of 110-160 beats/min., so there is no need to inform the doctor.

Page Ref: 504

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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18) Upon assessing the FHR 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.

Select all that apply.

1. Early fetalhypoxia

2. Prolonged fetal stimulation

3. Fetal anemia

4. Fetal sleep cycle

5. Infection

Answer: 1, 2, 3, 5

Explanation: 1. Early fetal hypoxia can cause fetal tachycardia.

2. Prolonged fetal stimulation can cause fetal tachycardia.

3. Fetal anemia can cause fetal tachycardia.

5. Infection can cause fetal tachycardia.

Page Ref: 493

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

19) Persistent early decelerations are noted. What would the nurses first action be?

1. Turn the mother on her left side and give oxygen.

2. Check for prolapsed cord.

3. Do nothing. This is a benign pattern.

4. Prepare for immediate forceps or cesarean delivery.

Answer: 3

Explanation: 3. Early decelerations are considered benign, and do not require any intervention.

Page Ref: 497

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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20) The laboring clients 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?

1. Document the fetal heart rate.

2. Apply oxygen via mask at 10 liters.

3. Prepare for imminent delivery.

4. Assist the client into Fowlers position.

Answer: 1

Explanation: 1. The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary.

Page Ref: 498, 499

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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21) The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Maternal dehydration

2. Maternal hyperthyroidism

3. Fetal hypoxia

4. Prematurity

5. Anesthesia or regional analgesia

Answer: 1, 2, 3, 4

Explanation: 1. Maternal dehydration can cause fetal tachycardia.

2. Maternal hyperthyroidism can cause fetal tachycardia.

3. Fetal tachycardia can indicate fetal hypoxia.

4. Prematurity can cause fetal tachycardia.

Page Ref: 493

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Examine the differences between fetal tachycardia and fetal bradycardia.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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22) The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Maternal hypotension

2. Prolonged umbilical cord compression

3. Fetal dysrhythmia

4. Central nervous system malformation

5. Late fetal asphyxia

Answer: 1, 2, 3, 5

Explanation: 1. Maternal hypotension results in decreased blood flow to the fetus.

2. Cord compression can cause fetal bradycardia.

3. This will cause fetal bradycardia if there is a fetal heart block.

5. This is a depression of myocardial activity.

Page Ref: 494

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Management of Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Examine the differences between fetal tachycardia and fetal bradycardia.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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23) The nurse is caring for a client in the transition phase of labor and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Provide caring labor support.

2. Administer oxygen via face mask.

3. Change the clients position.

4. Speed up the clients intravenous.

5. Reassure the client and her partner that she is doing fine.

Answer: 1, 5

Explanation: 1. The tracing is normal, so the nurse can continue support of the labor.

5. The nurse can reassure the client at this time, as the tracing is normal.

Page Ref: 504

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9 Evaluate abnormal findings on a fetal heart rate tracing.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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

1. Change the clients position in bed.

2. Notify the physician that birth is imminent.

3. Administer oxygen at 2 liters per minute.

4. Begin continuous fetal heart rate monitoring.

Answer: 4

Explanation: 4. Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring.

Page Ref: 483

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

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Copyright 2016 Pearson Education, Inc.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

25) A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurses teaching?

1. The most important part of fetal heart monitoring is the absence of variable decelerations.

2. The most important part of fetal heart monitoring is the presence of variability.

3. The most important part of fetal heart monitoring is the fetal heart rate baseline.

4. The most important part of fetal heart monitoring is the depth of decelerations.

Answer: 2

Explanation: 2. Baseline variability is a reliable indicator of fetal cardiac and neurologic function and well-being. The opposing push-pull balancing between the sympathetic nervous system and the parasympathetic nervous system directly affects the FHR.

Page Ref: 495

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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Copyright 2016 Pearson Education, Inc.

26) The fetal heart rate baseline is 140 beats/min. 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. Assist the client to change position.

2. Apply oxygen to the client at 2 liters per nasal cannula.

3. Notify the operating room of the need for a cesarean birth.

4. Determine the color of the leaking amniotic fluid.

Answer: 1

Explanation: 1. The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the womans upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava.

Page Ref: 500, 501

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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Copyright 2016 Pearson Education, Inc.

27) The nurse is caring for a client who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Fetal anemia

2. Chronic fetal bleeding

3. Maternal hypotension

4. Twin-to-twin transfusion

5. Umbilical cord occlusion

Answer: 1, 2, 4, 5

Explanation: 1. Fetal anemia can cause a sinusoidal heart rate.

2. Chronic fetal bleeding can cause a sinusoidal heart rate.

4. Twin-to-twin transfusion will cause a sinusoidal heart rate.

5. Umbilical cord occlusion can cause a sinusoidal fetal heart rate.

Page Ref: 494, 495

Cognitive Level: Evaluating

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

20

Copyright 2016 Pearson Education, Inc.

28) Fetal factors that possibly indicate electronic fetal monitoring include which of the following?

1. Meconium passage

2. Multiple gestation

3. Preeclampsia

4. Grand multiparity

5. Decreased fetal movement

Answer: 1, 2, 5

Explanation: 1. Meconium passage is an indicator for electronic fetal monitoring.

2. Multiple gestation is an indicator for electronic fetal monitoring.

5. Decreased fetal movement is an indicator for electronic fetal monitoring.

Page Ref: 492

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

29) The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention?

1. Early decelerations with each contraction

2. Variable decelerations that recover to the baseline

3. Late decelerations with minimal variability

4. Accelerations

Answer: 3

Explanation: 3. Late decelerations are considered a nonreassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention.

Page Ref: 494

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10 Explain the interventions that are indicated when a nonreassuring fetal heart rate pattern is identified.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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Copyright 2016 Pearson Education, Inc.

30) The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following?

1. Moderate variability

2. Early decelerations

3. Late decelerations

4. Accelerations

Answer: 3

Explanation: 3. Late decelerations are caused by uteroplacental insufficiency. The late deceleration pattern is considered a nonreassuring sign.

Page Ref: 499

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10 Explain the interventions that are indicated when a nonreassuring fetal heart rate pattern is identified.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

31) After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what?

1. Increase the mothers oxygen rate.

2. Turn the mother to the left lateral position.

3. Prepare the mother for a higher-risk delivery.

4. Increase the intravenous infusion rate.

Answer: 3

Explanation: 3. Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk.

Page Ref: 483

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

22

Copyright 2016 Pearson Education, Inc.

32) The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip?

1. Late decelerations

2. Early decelerations

3. Accelerations

4. Fetal dysrhythmia

Answer: 3

Explanation: 3. A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the FHR.

Page Ref: 504, 505

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11 Describe the steps used to perform fetal scalp stimulation.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

33) The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The clients partner asks why the nurse did that. What is the best response by the nurse?

1. I stimulated the top of the fetuss head to wake him up a little.

2. I stimulated the top of the fetuss head to try to get his heart rate to accelerate.

3. I stimulated the top of the fetuss head to calm the fetus down before birth.

4. I stimulated the top of the fetuss head to find out whether he is in distress.

Answer: 2

Explanation: 2. Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being.

Page Ref: 497

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Describe the steps used to perform fetal scalp stimulation.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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Copyright 2016 Pearson Education, Inc.

34) The primary care provider is performing a fetal scalp stimulation test. What result would the nurse hope to observe?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Spontaneous fetal movement

2. Fetal heart acceleration

3. Increase in fetal heart variability

4. Resolution of late decelerations

5. Reactivity associated with the stimulation

Answer: 2, 5

Explanation: 2. The fetal heart rate should accelerate with stimulation.

5. There will be some reaction with the stimulation.

Page Ref: 504, 505

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11 Describe the steps used to perform fetal scalp stimulation.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

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