Preview Extract
Chapter 18
1) The nurse is admitting a patient to the labor and delivery unit. Which aspect of the
patient’s history requires notifying the physician?
1. Blood pressure 120/88
2. Father is a carrier of sickle-cell trait
3. Dark red vaginal bleeding
4. History of domestic abuse
Answer: 3
Rationale 1:
Blood pressure 120/88. Although the diastolic reading is slightly elevated, this is not the top
priority.
Rationale 2:
The infant also might have sickle trait, but sickle trait is not life-threatening at this time.
Rationale 3:
Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red
bleeding usually indicates abruptio placentae, which is life-threatening to both the mother and
fetus.
Rationale 4:
This patient is at risk for harm after delivery but is not in a life-threatening situation at this
time. This is not the highest priority for the patient.
2) 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?
1. “You are going to do a vaginal exam to see how far dilated my cervix is.”
2. “The reason for a pelvic exam is to determine how low in the pelvis my baby is.”
3. “When you check my cervix, you will find out how thinned out it is.”
4. “After you assess my pelvis, you will be able to tell when I will deliver.”
Answer: 4
Rationale 1:
Cervical dilation is one aspect of the pelvic exam assessment.
Rationale 2:
Determining the station of the presenting part is one aspect of the pelvic exam assessment.
Rationale 3:
Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic exam
assessment.
Rationale 4:
An experienced labor and birth nurse can estimate the time of delivery based on the cervix,
fetal position, station, and contraction pattern. However, during a pelvic exam, no
information is obtained about the contractions. The nurse will not have enough information
following the cervical exam to estimate time of birth.
3) The nurse is working with a pregnant adolescent. The patient asks the nurse how the
baby’s condition is determined during labor. Which statement indicates the patient education
was successful? “During labor, the nurse will:
1. “Check your cervix by doing a pelvic exam every two hours.”
2. “Assess the baby’s heart rate with an electronic fetal monitor.”
3. “Look at the color and amount of bloody show that you have.”
4. “Verify that your contractions are strong but not too close together.”
Answer: 2
Rationale 1:
Although cervical exams are performed on a regular basis, the pelvic exam does not assess
fetal status. The patient has asked specifically about assessing fetal status in labor.
Rationale 2:
This option best answers the question the patient has asked.
Rationale 3:
Although bloody show is monitored, doing so does not assess fetal status. The patient has
asked specifically about assessing fetal status in labor.
Rationale 4:
Although contraction strength is palpated abdominally, the patient has asked about assessing
fetal status in labor.
4) The nurse is preparing to assess the fetus of a laboring patient. Which assessment should
the nurse perform first?
1. Perform Leopold’s maneuver to determine fetal position.
2. Count the fetal heart rate for 30 seconds and multiply by two.
3. Dry the maternal abdomen before using the Doppler.
4. Place the patient into a left lateral position.
Answer: 1
Rationale 1:
This is the first step so that the Doppler device can be placed directly over the heart, and
multiple unsuccessful attempts to hear the heart rate are avoided.
Rationale 2:
Although this is how to auscultate the fetal heart rate, it is better to perform Leopold’s
maneuver to determine fetal position so that the Doppler device can be placed directly over
the heart, and multiple unsuccessful attempts to hear the heart rate are avoided.
Rationale 3:
Prior to using the Doppler device, a water-based gel is applied to the skin.
Rationale 4:
The fetal heart tone assessment should be performed while the patient is either supine with a
lateral tilt or while in left lateral position. Leopold’s maneuver is performed first to determine
where to listen for fetal heart tones.
5) The student nurse is to perform Leopold’s maneuver on a laboring patient. Which
assessment requires intervention by the staff nurse?
1. The patient is assisted into supine position, and the position of the fetus is assessed.
2. The upper portion of the uterus is palpated, and then the middle section.
3. After determining where the back is located, the cervix is assessed.
4. Following voiding, the patient’s abdomen is palpated from top to bottom.
Answer: 3
Rationale 1:
Determination of fetal position and station is the point of Leopold’s maneuver. The patient is
supine to facilitate uterine palpation.
Rationale 2:
This is correct order of the first and second Leopold’s maneuver.
Rationale 3:
The cervical exam is not a part of Leopold’s maneuvers abdominal palpation is the only
technique used for Leopold’s maneuver.
Rationale 4:
The patient is instructed to void prior to beginning Leopold’s maneuver to facilitate comfort;
Leopold’s maneuver is essentially palpation of the uterus through the abdomen, beginning at
the fundus and ending near the cervix.
6) 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:
1. Whether the fetal head or buttocks occupies the uterine fundus.
2. The location of the fetal back.
3. Whether the pelvic inlet contains the head or buttocks.
4. The descent of the presenting part into the pelvis.
Answer: 2
Rationale 1:
The first maneuver determines what part of the fetus is in the fundus.
Rationale 2:
The second Leopold’s maneuver determines the location of the fetal back.
Rationale 3:
The third maneuver determines which fetal part is in the pelvic inlet.
Rationale 4:
The fourth maneuver determines the flexion of the fetal neck and descent into the pelvis.
7) The charge nurse is looking at the charts of laboring patients. Which patient most requires
further intervention?
1. Multip at 7 cm, fetal heart tones auscultated every 90 minutes
2. Primip at 10 cm and pushing, external fetal monitor applied
3. Multip with meconium-stained fluid, internal fetal scalp electrode in use
4. Primip in preterm labor, external monitor in place
Answer: 1
Rationale 1:
During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90
minutes is too infrequently.
Rationale 2:
External monitoring can be used instead of auscultation of the fetal heart tones during labor.
Rationale 3:
Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with
the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is
present.
Rationale 4:
External monitoring during preterm labor will assess both contractions and fetal status.
8) 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?
1. “The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5
beats per minute is the baseline rate.”
2. “The baseline FHR should include periodic or episodic changes in FHR.”
3. “Normal baseline FHR ranges from 100 to 180 beats per minute.”
4. “The baseline FHR excludes periods of marked variability.”
Answer: 4
Rationale 1:
The baseline rate is the mean FHR during a 10-minute period rounded to increments of 5
beats per minute (bpm).
Rationale 2:
The baseline FHR excludes periodic or episodic changes and periods of marked variability.
Rationale 3:
Normal FHR (baseline rate) ranges from 110 to 160 beats per minute.
Rationale 4:
The baseline FHR excludes periodic or episodic changes and periods of marked variability.
9) 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?
1. Acceleration
2. Late deceleration
3. Sinusoidal pattern
4. Tachycardia
Answer: 4
Rationale 1:
Accelerations are periodic changes of the fetal heart rate.
Rationale 2:
Late decelerations are periodic changes of the fetal heart rate.
Rationale 3:
A sinusoidal pattern is a periodic change of the fetal heart rate.
Rationale 4:
Bradycardia and tachycardia are changes in the fetal heart rate baseline.
10) 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?
1. Assist the patient to change from Fowler’s to left lateral position.
2. Apply oxygen to the patient at 2 liters per nasal cannula.
3. Notify the operating room of the need for a cesarean birth.
4. Determine the color of the leaking amniotic fluid.
Answer: 1
Rationale 1:
The fetus is exhibiting variable decelerations, which are caused by cord compression.
Repositioning the patient might get the fetus off the cord and eliminate the variable
decelerations.
Rationale 2:
Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting
variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are
preferable.
Rationale 3:
There is no indication that a cesarean delivery is needed. The fetus is exhibiting variable
decelerations.
Rationale 4:
The fetus is exhibiting variable decelerations; there is no indication that the amniotic fluid is
meconium-stained or bloody.
11) 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:
1. “Absence of variable decelerations.”
2. “Presence of variability.”
3. “Fetal heart rate baseline.”
4. “Depth of decelerations.”
Answer: 2
Rationale 1:
Variable decelerations indicate cord compression.
Rationale 2:
Variability is an indicator of the interplay between the sympathetic nervous system and the
parasympathetic nervous system.
Rationale 3:
The fetal heart rate baseline does not indicate central nervous system function.
Rationale 4:
The depth of decelerations does not indicate central nervous system function.
12) 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:
1. Change the patient’s position in bed.
2. Notify the physician that birth is imminent.
3. Administer oxygen at 2 liters per minute.
4. Begin continuous fetal heart rate monitoring.
Answer: 4
Rationale 1:
Changing the patient’s position is not indicated.
Rationale 2:
Meconium-stained amniotic fluid does not indicate that birth is imminent.
Rationale 3:
Oxygen administration is not indicated.
Rationale 4:
Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for
continuous fetal monitoring.
13) The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus
develops late decelerations. Which nursing intervention should be implemented first?
1. Alert the physician/CNM of the fetal status.
2. Administer oxygen to the patient at 4 liters per minute via nasal cannula.
3. Decrease the rate of infusion of intravenous fluids.
4. Facilitate a maternal left lateral position.
Answer: 4
Rationale 1:
While the attending physician or CNM should be notified, the priority nursing interventions
target alleviation of the causative factors by way of direct patient care. Initially, the mother
should be placed in the left lateral position.
Rationale 2:
Initially, the mother should be placed in the left lateral position to promote maximal
uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 liters per
minute via facemask.
Rationale 3:
Nursing interventions indicated in the treatment of late decelerations include increasing the
rate of administration of intravenous fluids.
Rationale 4:
In the treatment of late decelerations, the mother should immediately be placed in the left
lateral position in order to promote maximal uteroplacental blood flow.
14) 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:
1. “Is necessary so we can see how your labor is progressing.”
2. “Will prevent complications from the meconium in your fluid.”
3. “Helps us to see how the baby is tolerating labor.”
4. “Can be removed, and oxygen can be given instead.”
Answer: 3
Rationale 1:
The fetal monitor does not help visualize labor progress. Labor progress is assessed through
the pelvic exam, checking to see if the cervix is dilating and the fetus descending into the
pelvis.
Rationale 2:
The fetal monitor will provide information on how the baby is tolerating labor, but it does not
prevent complications such as meconium aspiration syndrome.
Rationale 3:
This is the reason fetal monitoring is used.
Rationale 4:
Oxygen is an appropriate intervention for late decelerations, but no information is given
about the fetal heart rate. Fetal monitoring provides information on the status of the fetus, and
it is a necessary assessment when the amniotic fluid is meconium-stained.
15) 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?
1. Application of a fetal heart monitor followed by an explanation of the reason for its use
2. Upon entering the patient’s room, speaking with the patient prior to looking at the fetal
heart monitor
3. Using layman’s terms to provide the patient with an explanation of the rationale for
electronic fetal monitoring
4. Incorporating cues that arise from intuition or from observations of the patient and family
as opposed to focusing on the fetal heart monitor
Answer: 1
Rationale 1:
Before using the electronic fetal monitor, the nurse needs to fully explain to the patient the
reason for its use and the information that it can provide.
Rationale 2:
The nurse can acknowledge the patient’s need to be the central focus by always speaking to
and looking at the woman when entering the room, before looking at the monitor.
Rationale 3:
The technical language of electronic fetal monitoring and other procedures may act as a
barrier, isolating the patient and emphasizing her experience.
Rationale 4:
To prevent dehumanization of the nurse-patient relationship, the nurse should incorporate
cues that may arise from intuition or from observations of or interactions with the patient and
family, as opposed to focusing only upon objective monitor-based data.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
