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C15.pdf
Course
Pharmacology (NUR 3145)
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Santa Fe College
Academic year: 2022/2023
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Labour|Maternal child nursing care
MULTIPLE CHOICE
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
nurse’s first priority is to:
a. change the woman’s position.
b. notify the care provider.
c. assist with amnioinfusion.
d. insert a scalp electrode.
ANS: A
Late decelerations may be caused by maternal supine hypotension syndrome. They usually are
corrected when the woman turns on 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, the nurse would continue with subsequent intrauterine resuscitation measures,
including notifying the 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 reveals variable deceleration. A fetal scalp electrode would provide accurate data for
evaluating the well-being of the fetus; however, this is not a nursing intervention that would
alleviate late decelerations, nor is it the nurse’s first priority.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
PTS: 1 DIF: CognitiNveURLeSvINelG: TABp
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
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.
ANS: A
Early decelerations are the fetus’s response to fetal head compression. Variable decelerations
are associated with umbilical cord compression. Late decelerations are associated with
uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal
heart rate unless the umbilical cord prolapses, which would result in variable or prolonged
bradycardia.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The nurse providing care for the laboring woman comprehends that accelerations with
fetal movement:
a. are reassuring.
b. are caused by umbilical cord compression.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
FHR. Fetal hypoxemia would result in tachycardia initially and then bradycardia if hypoxia
continues.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
NURSINGTB
The nurse providing care for the laboring woman should understand that late fetal heart
rate (FHR) decelerations are the result of:
a. altered cerebral blood flow.
b. umbilical cord compression.
c. uteroplacental insufficiency.
d. meconium fluid.
ANS: C
Uteroplacental insufficiency would result in late decelerations in the FHR. Altered fetal
cerebral blood flow would result in early decelerations in the FHR. Umbilical cord
compression would result in variable decelerations in the FHR. Meconium-stained fluid may
or may not produce changes in the fetal heart rate, depending on the gestational age of the
fetus and whether other causative factors associated with fetal distress are present.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
The nurse providing care for the laboring woman should understand that amnioinfusion is
used to treat:
a. variable decelerations.
b. late decelerations.
c. fetal bradycardia.
d. fetal tachycardia.
ANS: A
Amnioinfusion is used during labor either to dilute meconium-stained amniotic fluid or to
supplement the amount of amniotic fluid to reduce the severity of variable decelerations
caused by cord compression. Amnioinfusion has no bearing on late decelerations, fetal
bradycardia, or fetal tachycardia alterations in fetal heart rate (FHR) tracings.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
The nurse caring for the woman in labor should understand that maternal hypotension
can result in:
a. early decelerations.
b. fetal dysrhythmias.
c. uteroplacental insufficiency.
d. spontaneous rupture of membranes.
ANS: C
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
b. oxytocin administration.
c. regional anesthesia.
d. intravenous 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 reduces
venous return to the woman’s heart, as well as cardiac output, and subsequently reduces her
blood pressure. The nurse can encourage the woman to change positions and avoid the supine
position. Oxytocin administration, regional anesthesia, and intravenous analgesic may reduce
maternal cardiac output.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
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 patient’s record.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
ANS: D
The FHR indicates early decelerations, which are not an ominous sign and do not require any
intervention. The nurse should simply document these findings.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
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/min
d. Late decelerations
ANS: D
Late decelerations are caused by uteroplacental insufficiency and are associated with fetal
hypoxemia. They are considered ominous if persistent and uncorrected. Accelerations in the
FHR 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 generally are not
a concern during normal labor.
PTS: 1 DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
Fetal well-being during labor can be measured by the response of the FHR to UCs. In general,
reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160
beats/min with no periodic changes, a moderate baseline variability, and accelerations with
fetal movement. Maternal pain control is not the measure used to determine fetal well-being in
labor. Although FHR accelerations are a reassuring pattern, they are only one component of
the criteria by which fetal well-being is assessed. Although an FHR above 110 beats/min may
be reassuring, it is only one component of the criteria by which fetal well-being is assessed.
More information would be needed to determine fetal well-being.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
You are evaluating the fetal monitor tracing of your patient, who is in active labor. Suddenly
you see the fetal heart rate (FHR) drop from its baseline of 125 beats/min down to 80
beats/min. 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. Call for staff assistance.
b. Insert a Foley catheter.
c. Start Pitocin.
d. Notify the care provider immediately.
ANS: D
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and
provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not
resolve, the primary care provider should be notified immediately. Inserting a Foley catheter
is an inappropriate nursing action RthSeINFGHTRB to continue in a
nonrea ss uring pattern, a cesarean section could be warranted, which would require a Foley
catheter. However, the
physician must make that determination. Pitocin may place additional stress on the fetus.
PTS: 1 DIF: Cognitive Level: Evaluation
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
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.
d. Perform a vaginal examination, reposition the mother, and provide oxygen via face
mask.
ANS: B
Repositioning the mother, increasing intravenous (IV) fluid, and providing oxygen via face
mask are correct nursing actions for intrauterine resuscitation. The nurse should initiate
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
sure the woman is comfortable may be activities that a nurse performs, but they are not
activities for which the nurse is legally responsible.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment, Planning, Implementation
MSC: Client Needs: Safe and Effective Care Environment
As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or
has late decelerations or loss of variability is nonreassuring and is associated with:
a. hypotension.
b. cord compression.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
c. maternal drug use.
d. hypoxemia.
ANS: D
Nonreassuring heart rate patterns are associated with fetal hypoxemia. Fetal bradycardia may
be associated with maternal hypotension. Fetal variable decelerations are associated with cord
compression. Maternal drug use is associated with fetal tachycardia.
PTS: 1 DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
A new patient and her partner arrive in the labor, delivery, recovery, and after birth unit for
the birth of their first child. You apply 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 baby’s heart rate should be. Your best response is:
a. “Don’t worry about that machine; that’s my job.”
b. “The top line graphs the baby’s heart rate. Generally the heart rate is between 110
and 160. The heart 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.”
ANS: B
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
According to standard professional thinking, nurses should auscultate the fetal heart rate
(FHR): NURSINGTB
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
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.
ANS: C
The FHR should be auscultated before and after administration of medications and induction
of anesthesia. In the active phase of the first stage of labor, the FHR should be auscultated
every 30 minutes if no risk factors are involved; with risk factors it should be auscultated
every 15 minutes. In the second stage of labor the FHR should be auscultated every 15
minutes if no risk factors are involved; with risk factors it should be auscultated every 5
minutes. The fetus of a first-time mother is automatically at greater risk.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
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 patients 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.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
ANS: A
The assessment is done by palpation; duration, frequency, intensity, and resting tone must be
assessed. The duration of contractions is measured in seconds; the frequency is measured in
minutes. The intensit y of contractNioUnRs SuIsNuGaTllBy sOdMe scribed a s mild,
moderate, or strong. The resting tone usually is characterized as soft or relaxed.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
What is an advantage of external electronic fetal monitoring?
a. 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.
ANS: C
The tocotransducer is especially valuable for measuring uterine activity during the first stage
of labor, particularly when the membranes are intact. Short-term changes cannot be measured
with this technology. The tocotransducer cannot measure and record the intensity of UCs. The
transducer must be repositioned when the woman or fetus changes position.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
When assessing the relative advantages and disadvantages of internal and external
electronic fetal monitoring, nurses comprehend that both:
a. can be used when membranes are intact.
b. measure the frequency, duration, and intensity of uterine contractions.
c. may need to rely on the woman to indicate when uterine activity (UA) is occurring.
d. can be used during the antepartum and intrapartum periods.
ANS: D
External monitoring can be used in both periods; internal monitoring can be used only in the
intrapartum period. For internal monitoring the membranes must have ruptured, and the
cervix must be sufficiently dilated. Internal monitoring measures the intensity of contractions;
external monitoring cannot do this. With external monitoring, the woman may need to alert
the nurse that UA is occurring; internal monitoring does not require this.
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
During labor a fetus with an average heart rate of 135 beats/min over a 10-minute
period would be considered to have:
a. bradycardia.
b. a normal baseline heart rate.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Was this document helpful?
C15.pdf - C15.pdf
Course: Pharmacology (NUR 3145)
80 Documents
Students shared 80 documents in this course
University: Santa Fe College
Was this document helpful?
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
MULTIPLE CHOICE
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
nurse’s first priority is to:
a. change the woman’s position.
b. notify the care provider.
c. assist with amnioinfusion.
d. insert a scalp electrode.
ANS: A
Late decelerations may be caused by maternal supine hypotension syndrome. They usually are
corrected when the woman turns on 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, the nurse would continue with subsequent intrauterine resuscitation measures,
including notifying the 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 reveals variable deceleration. A fetal scalp electrode would provide accurate data for
evaluating the well-being of the fetus; however, this is not a nursing intervention that would
alleviate late decelerations, nor is it the nurse’s first priority.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
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