Download Fetal Assessment and Monitoring during Labor and more Exams Nursing in PDF only on Docsity!
Maternal Child Nursing Care Fetal
Assessment during Labor Chp: 15
A nurse may 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 fetal heart rate (FHR). - ✔✔d. To elicit an acceleration in the fetal heart rate (FHR). In assisting with the two factors that have an effect on fetal status (i.e., pushing and positioning), nurses should: a. Encourage the woman's 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. - ✔✔a. Encourage the woman's cooperation in avoiding the supine position. Fetal bradycardia is most common during: a. Intraamniotic infection. b. Fetal anemia. c. Prolonged umbilical cord compression. d. Tocolytic treatment using terbutaline. - ✔✔c. Prolonged umbilical cord compression.
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (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. The nurses first priority is to: a. Change the woman's position. b. Notify the care provider. c. Assist with amnioinfusion. d. Insert a scalp electrode. - ✔✔a. Change the woman's position. The nurse caring for the laboring woman should understand that early decelerations are caused by: a. Altered fetal cerebral blood flow. b. Umbilical cord compression. c. Uteroplacental insufficiency. d. Spontaneous rupture of membranes. - ✔✔a. Altered fetal cerebral blood flow. The nurse providing care for the laboring woman comprehends that accelerations with fetal movement: a. Are reassuring. b. Are caused by umbilical cord compression. c. Warrant close observation. d. Are caused by uteroplacental insufficiency. - ✔✔a. Are reassuring. The nurse providing care for the laboring woman realizes that variable fetal heart rate (FHR) decelerations are caused by: a. Altered fetal cerebral blood flow.
b. Oxytocin administration. c. Regional anesthesia. d. Intravenous analgesic. - ✔✔a. Change in position. While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should: a. Change the woman's position. b. Discontinue the oxytocin infusion. c. Insert an internal monitor. d. Document the finding in the client's record. - ✔✔d. Document the finding in the client's record. Which fetal heart rate (FHR) finding would concern the nurse during labor? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/mind. d Late decelerations - ✔✔d. Late decelerations The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: a. Altered cerebral blood flow. b. Fetal hypoxemia. c. Umbilical cord compression. d. Fetal sleep cycles. - ✔✔d. Fetal sleep cycles. Fetal well-being during labor is assessed by:
a. The response of the fetal heart rate (FHR) to uterine contractions (UCs). b. Maternal pain control. c. Accelerations in the FHR. d. An FHR above 110 beats/min. - ✔✔a. The response of the fetal heart rate (FHR) to uterine contractions (UCs). You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take? a. Scream for help. b. Insert a Foley catheter. c. Start Pitocin. d. Notify the care provider immediately. - ✔✔d. Notify the care provider immediately. What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. a. Call the provider, reposition the mother, and perform a vaginal examination. b. Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. c. Administer oxygen to the mother, increase IV fluid, and notify the care provider.
rate will fluctuate in response to what is happening during labor. c. The top line graphs the baby's heart rate, and the bottom line lets me know how strong the contractions are. d. Your doctor will explain all of that later. - ✔✔b. The top line graphs the baby's heart rate. Generally the heart rate is between 110 and
- The heart rate will fluctuate in response to what is happening during labor. A normal uterine activity pattern in labor is characterized by: a. Contractions every 2 to 5 minutes. b. Contractions lasting about 2 minutes. c. Contractions about 1 minute apart. d. A contraction intensity of about 1000 mm Hg with relaxation at 50 mm Hg. - ✔✔a. Contractions every 2 to 5 minutes. According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR): a. Every 15 minutes in the active phase of the first stage of labor in the absence of risk factors. b. Every 20 minutes in the second stage, regardless of whether risk factors are present. c. Before and after ambulation and rupture of membranes. d. More often in a woman's first pregnancy. - ✔✔c. Before and after ambulation and rupture of membranes. When using intermittent auscultation (IA) for fetal heart rate, nurses should be aware that: a. They 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 electronic fetal monitoring (EFM) when documenting results. c. If the heartbeat cannot be found immediately, a shift must be made to EFM. d. Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor. - ✔✔d. Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor. When using intermittent auscultation (IA) to assess uterine activity, the nurse should be cognizant that: a. The examiners hand should be placed over the fundus before, during, and after contractions. b. The frequency and duration of contractions is measured in seconds for consistency. c. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. d. The resting tone between contractions is described as either placid or turbulent. - ✔✔a. The examiners hand should be placed over the fundus before, during, and after contractions. The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the fetal heart rate. b. The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs). 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. - ✔✔c. The
Which deceleration of the fetal heart rate would not require the nurse to change the maternal position? a. Early decelerations b. Late decelerations c. Variable decelerations d. It is always a good idea to change the woman's position. - ✔✔a. Early decelerations What correctly matches the type of deceleration with its likely cause? a. Early decelerationumbilical cord compression b. Late decelerationuteroplacental inefficiency c. Variable decelerationhead compression d. Prolonged decelerationcause unknown - ✔✔b. Late decelerationuteroplacental inefficiency The nurse caring for a woman in labor understands that prolonged decelerations: a. Are a continuing pattern of benign decelerations that do not require intervention. b. Constitute a baseline change when they last longer than 5 minutes. c. Usually are isolated events that end spontaneously. d. Require the usual fetal monitoring by the nurse. - ✔✔c. Usually are isolated events that end spontaneously. The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine
contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should: a. Notify the woman's primary health care provider immediately. b. Prepare to administer an oxytocic to stimulate uterine activity. c. Document the findings because they reflect the expected contraction pattern for the active phase of labor. d. Prepare the woman for the onset of the second stage of labor. - ✔✔c. Document the findings because they reflect the expected contraction pattern for the active phase of labor. Which maternal condition is considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix dilated to 4 cm c. External monitors in current use d. Fetus with a known heart defect - ✔✔a. Unruptured membranes The nurse knows that proper placement of the tocotransducer for electronic fetal monitoring is located: a. Over the uterine fundus. b. On the fetal scalp. c. Inside the uterus. d. Over the mothers lower abdomen. - ✔✔a. Over the uterine fundus. Why is continuous electronic fetal monitoring usually used when oxytocin is administered? a. The mother may become hypotensive. b. Uteroplacental exchange may be compromised.
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 baby's neck e. Maternal supine hypotension - ✔✔c. Placental abruption e. Maternal supine hypotension Commonly 45 seconds or more in the second stage of labor - ✔✔Relaxation time Generally ranging from two to five contractions per 10 minutes of labor - ✔✔Frequency Average of 10 mmHg - ✔✔Duration Peaking at 40 to 70 mmHg in the first stage of labor - ✔✔Strength Remaining fairly stable throughout the first and second stages - ✔✔Resting tone
