Deck 23: Intrapartum Nursing Assessment

Question 1

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:

A) Breech presentation.
B) Uteroplacental insufficiency.
C) Compression of the fetal head.
D) Umbilical cord compression.

Answer 1

Umbilical cord compression.

Question 2

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

A) "You are going to do a vaginal exam to see how 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 2

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

Question 3

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 given instead."

Answer 3

"Helps us to see how the baby is tolerating labor."

Question 4

During the initial intrapartal assessment of a patient in early labor, the nurse performs a vaginal examination. The patient's 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 the:

A) Uterine contraction pattern.
B) Fetal position.
C) Presence of the mucous plug.
D) Cervical dilation and effacement.
E) Presenting part.

Question 5

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 a carrier of sickle-cell trait
C) Dark red vaginal bleeding
D) History of domestic abuse

Question 6

A primigravida patient 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 patient and her fetus?

A) Check for ruptured membranes and apply a fetal scalp electrode.
B) Auscultate the fetal heart rate between and during contractions.
C) Palpate contractions and resting uterine tone.
D) Assess the blood pressure, temperature, respiratory rate, and pulse rate.
E) Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers.

Question 7

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

A) Inform the maternal patient that the rate is normal.
B) Reassess the FHR in 5 minutes because the rate is low.
C) Report the FHR to the doctor immediately.
D) Turn the maternal patient on her side and administer oxygen.

Question 8

The nurse is caring for a patient who is having fetal tachycardia. The nurse knows that possible causes include:

A) Maternal dehydration.
B) Maternal hyperthyroidism.
C) Fetal hypoxia.
D) Prematurity.
E) Anesthesia or regional analgesia.

Question 9

The laboring patient's 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?

A) Document the fetal heart rate.
B) Apply oxygen via mask at 10 liters.
C) Prepare for imminent delivery.
D) Assist the patient into Fowler's position.

Question 10

Before performing Leopold's maneuvers, the nurse would:

A) Have the patient empty her bladder.
B) Place the patient in Trendelenburg position.
C) Have the patient lie on her back with her feet on the bed and knees bent.
D) Turn the patient to her left side.
E) Have the patient lie flat with her ankles crossed.

Question 11

Upon assessing the FHR tracing, the nurse determines that there is increased variability. The increased variability would be caused by:

A) Early mild hypoxia.
B) Fetal stimulation.
C) Alterations in placental blood flow.
D) Fetal sleep cycle.
E) Increased uterine contractions.

Question 12

The charge nurse is looking at the charts of laboring patients. Which patient is in greatest need of further intervention?

A) Multip at 7 cm, fetal heart tones auscultated every 90 minutes
B) Primip at 10 cm and pushing, external fetal monitor applied
C) Multip with meconium-stained fluid, internal fetal scalp electrode in use
D) Primip in preterm labor, external monitor in place

Question 13

A laboring patient 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:

A) The IUPC can be used throughout the birth process.
B) A tocodynamometer is subject to artifacts.
C) The IUPC provides more accurate data than does the tocodynamometer.
D) The tocodynamometer can be used only after the cervix is dilated 2 cm.

Question 14

The nurse is working with a pregnant adolescent. The patient asks the nurse how the baby's condition is determined during labor. The nurse's best response is that during labor, the nurse will:

A) Check the patient's cervix by doing a pelvic exam every 2 hours.
B) Assess the baby's heart rate with an electronic fetal monitor.
C) Look at the color and amount of bloody show that the patient has.
D) Verify that the patient's contractions are strong but not too close together.

Question 15

Persistent early decelerations are noted. The nurse's first action would be to:

A) Turn the mother on her left side and give oxygen.
B) Check for prolapsed cord.
C) Do nothing. This is a benign pattern.
D) Prepare for immediate forceps or cesarean delivery.

Question 16

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

A) "Your baby is taking a little longer than average, but is making progress."
B) "First babies take a long time to be born. The next baby will be easier."
C) "The birth would go faster if you had taken prenatal classes and practiced."
D) "Every baby is different; there really are no norms for labor and birth."

Question 17

The nurse is admitting a patient to the birthing unit. What should the nurse ask to gain a better understanding of the patient's psychosocial status?

A) "How did you decide to have your baby at this hospital?"
B) "Who will be your labor support person?"
C) "Have you chosen names for your baby yet?"
D) "What feeding method will you use for your baby?"

Question 18

During a maternal assessment, the nurse determines the fetus to be in a left occipitoanterior (LOA) position. Auscultation of the fetal heart rate should begin in the:

A) Right upper quadrant.
B) Left upper quadrant.
C) Right lower quadrant.
D) Left lower quadrant.

Question 19

The nurse has just palpated contractions and compares the consistency to that of the forehead. The intensity of these contractions would be identified as:

A) Mild.
B) Moderate.
C) Strong.
D) Weak.

Question 20

The student nurse is to perform Leopold's maneuvers on a laboring client. 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, 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 21

The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be:

A) Moderate long-term variability.
B) Early decelerations.
C) Late decelerations.
D) Accelerations.

Question 22

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?

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 23

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 24

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

A) Spontaneous fetal movement
B) Fetal heart acceleration
C) Increase in fetal heart variability
D) Resolution of late decelerations
E) Reactivity associated with the stimulation

Question 25

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

A) Early decelerations with each contraction
B) Variable decelerations that recover to the baseline
C) Late decelerations with minimal variability
D) Accelerations

Question 26

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:

A) Maternal hypotension.
B) Prolonged umbilical cord compression.
C) Fetal dysrhythmia.
D) Central nervous system malformation.
E) Late fetal asphyxia.

Question 27

The nurse is analyzing fetal cord blood results. If the fetal blood pH is below 7.25, the nurse can conclude that the fetus was:

A) Acidotic and hypoxic.
B) Alkalotic and hypoxic.
C) Well oxygenated.
D) Alkalotic but well oxygenated.

Question 28

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?

A) Late decelerations
B) Early decelerations
C) Accelerations
D) Increased long-term variability

Question 29

The primigravida patient 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 patient's partner asks why the nurse did that. What is the best response by the nurse? "I stimulated the top of the baby's head to:

A) "Wake him up a little."
B) "Try to get his heart rate to accelerate."
C) "Calm the baby down before birth."
D) "Find out whether he is in distress."

Question 30

After noting meconium-stained amniotic fluid, fetal heart rate decelerations, and a fetal blood pH of 7.20, the physician diagnoses a severely depressed fetus. The appropriate nursing action at this time would be to:

A) Increase the mother's oxygen rate.
B) Turn the mother to the left lateral position.
C) Prepare the mother for a forceps or cesarean birth.
D) Increase the intravenous infusion rate.

Question 31

The nurse is caring for a patient who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include:

A) Fetal anemia.
B) Chronic fetal bleeding.
C) Maternal hypotension.
D) Twin-to-twin transfusion.
E) Umbilical cord occlusion.

Question 32

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 33

The nurse is caring for a patient 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?

A) Provide caring labor support.
B) Administer oxygen via face mask.
C) Change the patient's position.
D) Speed up the patient's intravenous.
E) Reassure the patient and her partner that she is doing fine.