Question 1

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

Accepted Answer

The statement "After you assess my pelvis, you will be able to tell when I will deliver" is incorrect. A pelvic exam can give information about the baby's position in the pelvis, but it cannot predict with certainty when the patient will deliver. Labor progress is influenced by many factors and can vary from person to person. It is important for the nurse to provide accurate information and manage the patient's expectations about labor and delivery.

Question 2

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

Accepted Answer

Leopold's maneuvers are performed first to determine the fetal position, which helps in deciding the best location to auscultate the fetal heart rate.

Question 3

The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first?

Accepted Answer

Facilitating a maternal left lateral position is the first nursing intervention to implement in cases of late decelerations, as this can improve fetal oxygenation by decreasing pressure on the inferior vena cava and increasing blood flow to the uterus. It is important to reposition the mother before administering oxygen or notifying the physician/CNM. Decreasing the rate of infusion of intravenous fluids may be necessary if the patient is experiencing fluid overload or if there is concern for placental perfusion, but this is not the first intervention to implement in this scenario.

Question 4

The student nurse is to perform Leopold's maneuver on a laboring patient. Which assessment requires intervention by the staff nurse?

Accepted Answer

It is not appropriate to assess the cervix during Leopold's maneuver, as this is typically done through a vaginal exam. This assessment requires intervention by the staff nurse to correct the student nurse's understanding of the procedure. The other choices describe appropriate steps in performing Leopold's maneuver.

Question 5

While orienting a new nurse to the obstetrics unit, the R.N. preceptor is describing how to determine the baseline (BL) fetal heart rate (FHR). Which statement should the R.N. preceptor include in order to accurately describe the BL FHR?

Accepted Answer

The baseline fetal heart rate excludes periods of marked variability, as these are not considered part of the baseline.

Question 6

The clinical coordinator is observing a nursing student as he provides care to a patient who is in early labor. Which of the student's actions should be addressed for correction during the student's daily clinical evaluation?

Accepted Answer

The correct action is to first explain the procedure to the patient before applying the fetal heart monitor to ensure informed consent and patient understanding.

Question 7

The nurse is admitting a patient to the labor and delivery unit. Which aspect of the patient's history requires notifying the physician?

Accepted Answer

Dark red vaginal bleeding is a concerning sign in a patient being admitted to the labor and delivery unit and requires notifying the physician. It may indicate a placental abruption, which is a serious complication that requires immediate medical attention. Blood pressure, sickle-cell trait, and history of domestic abuse are all important aspects of the patient's history, but they do not require immediate notification of the physician.

Question 8

A woman is in labor. The fetus is in vertex position. When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately:

Accepted Answer

Meconium-stained amniotic fluid indicates that the fetus may have passed meconium, which can lead to respiratory distress if inhaled. Continuous fetal heart rate monitoring will allow the nurse to monitor the fetus for distress and take appropriate actions if necessary. Changing the patient's position and administering oxygen may also be necessary, but they should be done after monitoring the fetal heart rate. Notifying the physician is important but is not the immediate action required in this situation.

Question 9

The primigravida 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 patient understands the nurse's teaching? "The most important part of fetal heart monitoring is the:

Accepted Answer

The patient's understanding is demonstrated by selecting choice B, which correctly identifies the presence of variability as the most important part of fetal heart monitoring. Variability is an indication of the fetal neurological system's response to stimuli, and is therefore a reassuring sign of fetal well-being. While the absence of variable decelerations is preferable, their presence alone does not signify distress. The fetal heart rate baseline and depth of decelerations are important components to monitor, but are not the most important aspects.

Question 10

Which of the following, if seen on an electronic fetal monitoring strip, would the nurse explain to a laboring patient as a change in the baseline fetal heart rate?

Accepted Answer

Tachycardia refers to an increased baseline fetal heart rate, which is a change from the normal range (usually considered above 160 beats per minute for a fetus). Accelerations and decelerations are temporary fluctuations in the heart rate in response to contractions or fetal movements, and a sinusoidal pattern is a specific waveform pattern, not a change in baseline rate.

Question 11

The nurse is explaining to a student nurse how to determine fetal presentation and position by performing Leopold's maneuver. The nurse should explain that the second maneuver in this procedure is used to determine:

Accepted Answer

The second maneuver in Leopold's maneuver is used to determine the location of the fetal back. This is important because it allows the healthcare provider to determine the position of the baby in the uterus and to identify any potential concerns or complications, such as a breech presentation. Knowing the position of the fetal back can also help in determining the best positioning for delivery.

Question 12

The fetal heart rate baseline is 140 beats per minute. 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?

Accepted Answer

A sudden drop in fetal heart rate during contractions followed by a rapid return to baseline suggests a possible umbilical cord compression. Changing the patient's position can relieve pressure on the cord and restore normal fetal heart rate. Applying oxygen and determining the color of amniotic fluid may be important interventions, but they are not the priority in this situation. A cesarean birth may be needed if the fetal heart rate does not recover, but it is not the first intervention to consider.

Question 13

The laboring primiparous patient 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? "The monitor:

Accepted Answer

The fetal monitor is necessary to assess how the baby is tolerating labor, particularly in the case of meconium-stained amniotic fluid, which can indicate fetal distress. It allows the healthcare team to identify any potential problems and intervene if necessary to ensure a safe delivery. While it is true that the monitor provides information on the progress of labor, this is not the most important reason for its use in this situation. B and D are incorrect as they do not fully address the patient's question and may not be entirely accurate.

Quiz 18: Intrapartum Nursing Assessment