Deck 18: Intrapartum Nursing Assessment

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?

A)"You are going to do a vaginal exam to see how far dilated my cervix is."
B)"The reason for a pelvic exam is to determine how low in the pelvis my baby is."
C)"When you check my cervix, you will find out how thinned out it is."
D)"After you assess my pelvis, you will be able to tell when I will deliver."

Answer 1

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

Question 2

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

A)Perform Leopold's maneuver to determine fetal position.
B)Count the fetal heart rate for 30 seconds and multiply by two.
C)Dry the maternal abdomen before using the Doppler.
D)Place the patient into a left lateral position.

Answer 2

Perform Leopold's maneuver to determine fetal position.

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?

A)Alert the physician/CNM of the fetal status.
B)Administer oxygen to the patient at 4 liters per minute via nasal cannula.
C)Decrease the rate of infusion of intravenous fluids.
D)Facilitate a maternal left lateral position.

Answer 3

Facilitate a maternal left lateral position.

Question 4

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

A)The patient is assisted into supine position, and the position of the fetus is assessed.
B)The upper portion of the uterus is palpated, and then the middle section.
C)After determining where the back is located, the cervix is assessed.
D)Following voiding, the patient's abdomen is palpated from top to bottom.

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?

A)"The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute is the baseline rate."
B)"The baseline FHR should include periodic or episodic changes in FHR."
C)"Normal baseline FHR ranges from 100 to 180 beats per minute."
D)"The baseline FHR excludes periods of marked variability."

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?

A)Application of a fetal heart monitor followed by an explanation of the reason for its use
B)Upon entering the patient's room, speaking with the patient prior to looking at the fetal heart monitor
C)Using layman's terms to provide the patient with an explanation of the
D)Incorporating cues that arise from intuition or from observations of the patient and family as opposed to focusing on the fetal heart monitor

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?

A)Blood pressure 120/88
B)Father is a carrier of sickle-cell trait
C)Dark red vaginal bleeding
D)History of domestic abuse

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:

A)Change the patient's position in bed.
B)Notify the physician that birth is imminent.
C)Administer oxygen at 2 liters per minute.
D)Begin continuous fetal heart rate monitoring.

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:

A)"Absence of variable decelerations."
B)"Presence of variability."
C)"Fetal heart rate baseline."
D)"Depth of decelerations."

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?

A)Acceleration
B)Late deceleration
C)Sinusoidal pattern
D)Tachycardia

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:

A)Whether the fetal head or buttocks occupies the uterine fundus.
B)The location of the fetal back.
C)Whether the pelvic inlet contains the head or buttocks.
D)The descent of the presenting part into the pelvis.

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?

A)Assist the patient to change from Fowler's to left lateral position.
B)Apply oxygen to the patient at 2 liters per nasal cannula.
C)Notify the operating room of the need for a cesarean birth.
D)Determine the color of the leaking amniotic fluid.

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:

A)"Is necessary so we can see how your labor is progressing."
B)"Will prevent complications from the meconium in your fluid."
C)"Helps us to see how the baby is tolerating labor."
D)"Can be removed, and oxygen can be given instead."