____  28.   The nurse is preparing to monitor the fetal heart rate (FHR) of a pregnant client. What should the nurse explain to a nursing student as being the baseline (BL) of this heart rate?

1.   “The baseline FHR excludes periods of marked variability.”

2.   “Normal baseline FHR ranges from 100 to 180 beats per minute.”

3.   “The baseline FHR should include periodic or episodic changes in FHR.”

4.   “The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute.”

____  29.   Which pattern, if seen on an electronic fetal monitoring strip, should the nurse explain to a client in labor as being a change in the baseline fetal heart rate?

1.   Tachycardia

2.   Acceleration

3.   Late deceleration

4.   Sinusoidal pattern

____  30.   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.   Determine the color of the leaking amniotic fluid.

2.   Apply oxygen to the client at 2 L per nasal cannula.

3.   Notify the operating room of the need for a cesarean birth.

4.   Assist the client to change from the Fowler position to the left lateral position.

____  31.   The nurse explains to a client in labor that the fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement about the most important part of fetal heart monitoring indicates that the client understands the nurse’s teaching?

1.   “Presence of variability”

2.   “Depth of decelerations”

3.   “Fetal heart rate baseline”

4.   “Absence of variable decelerations”

____  32.   A client’s amniotic fluid is meconium stained. What should the nurse do immediately?

1.   Change the client’s position in bed.

3.   Administer oxygen at 2 L per minute.

2.   Notify the healthcare provider that birth is imminent.

4.   Begin continuous fetal heart rate monitoring.

____  33.   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.   Facilitate a maternal left lateral position.

2.   Alert the healthcare provider of the fetal status.

3.   Decrease the rate of infusion of intravenous fluids.

4.   Administer oxygen to the client at 4 L per minute via nasal cannula.

____  34.   The client in labor with meconium-stained amniotic fluid asks why the fetal monitor is necessary because the belt is uncomfortable. What should the nurse explain about monitoring?

1.   “It helps us to see how the baby is tolerating labor.”

2.   “It can be removed, and oxygen can be given instead.”

3.   “It is necessary so we can see how your labor is progressing.”

4.   “It will prevent complications from the meconium in your fluid.”

____  35.   The nurse is observing a student provide care to a client who is in early labor. Which student actions should be corrected?

1.   Applying a fetal heart monitor followed by an explanation of the reason for its use

2.   Upon entering the room, speaking with the client prior to looking at the fetal heart monitor

3.   Using layman’s terms to provide the client with an explanation of the reason for electronic fetal monitoring

4.   Incorporating cues that arise from intuition or from observations of the client and family as opposed to focusing on the fetal heart monitor

____  36.   A laboring client 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 which of the following?

1. The IUPC can be used throughout the birth process.

2. A tocodynamometer is invasive.

3. The IUPC provides more accurate data than does the tocodynamometer.

4. The tocodynamometer can be used only after the cervix is dilated 2 cm.

____  37.   The nurse has just palpated contractions and compares the consistency to that of the forehead to estimate the firmness of the fundus. What would the intensity of these contractions be identified as?

1. Mild

2. Moderate

3. Strong

4. Weak

____  38.   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 which of the following?

1. Breech presentation

2. Uteroplacental insufficiency

3. Compression of the fetal head

4. Umbilical cord compression

____  39.   The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate?

1. Inform the maternal client that the rate is normal.

2. Reassess the FHR in 5 minutes because the rate is low.

3. Report the FHR to the doctor immediately.

4. Turn the maternal client on her side and administer oxygen.

____  40.   Persistent early decelerations are noted. What would the nurse's first action be?

1. Turn the mother on her left side and give oxygen.

2. Check for prolapsed cord.

3. Do nothing. This is a benign pattern.

4. Prepare for immediate forceps or cesarean delivery.

____  41.   The laboring client'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?

1. Document the fetal heart rate.

2. Apply oxygen via mask at 10 liters.

3. Prepare for imminent delivery.

4. Assist the client into Fowler's position.

____  42.   The nurse is admitting a client to the labor and delivery unit. Which aspect of the history requires notifying the healthcare provider?

1.   Blood pressure 120/88

2.   Dark red vaginal bleeding

3.   History of domestic abuse

4.   Father is a carrier of sickle-cell trait

____  43.   The nurse is preparing to assess a client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed?

1.   “When you check my cervix, you will find out how thinned out it is.”

2.   “After you assess my pelvis, you will be able to tell when I will deliver.”

3.   “You are going to do a vaginal examination to see how far dilated my cervix is.”

4.   “The reason for a pelvic examination is to determine how low in the pelvis my baby is.”

____  44.   The nurse is preparing to assess the fetus of a laboring client. Which should the nurse perform first?

1.   Place the client into a prone position.

2.   Perform the Leopold maneuver to determine fetal position.

3.   Dry the maternal abdomen before using the Doppler.

4.   Count the fetal heart rate for 30 seconds and multiply by 2.

____  45.   The student nurse is performing Leopold maneuvers on a client in labor. For which action should the staff nurse intervene?

1.   After determining where the back is located, the cervix is assessed.

2.   The upper portion of the uterus is palpated, and then the middle section.

3.   Following voiding, the client’s abdomen is palpated from top to bottom.

4.   The client is assisted into the supine position, and the position of the fetus is assessed.

____  46.   The nurse is explaining Leopold maneuvers to a client who is in the early stage of labor. What should the nurse explain as being the purpose of the second maneuver?

1.   Locate the fetal back

2.   Identify the descent of the presenting part into the pelvis

3.   Determine if the pelvic inlet contains the head or buttocks

4.   Determine if the fetal head or buttocks occupies the uterine fundus

____  47.   The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching about a client admission has been effective?”

1.   “A vaginal examination is performed if delivery appears to be imminent.”

2.   “Her prenatal record is reviewed for indications of domestic abuse.”

3.   “She will be positioned supine to facilitate a normal blood pressure.”

4.   “A urine specimen is obtained by catheter to check for protein and ketones.”

____  48.   The client in labor arrives at the birthing unit with her partner. Which step of the admission process should be completed first?

1.   Welcoming the couple

2.   The sterile vaginal examination

3.   Auscultation of the fetal heart rate

4.   Checking for ruptured membranes

____  49.   An expectant father has been at the bedside of his laboring partner for more than 12 hours. What would be an appropriate nursing intervention?

1.   Insist that he leave the room for at least the next hour.

2.   Offer to remain with his partner while he takes a break.

3.   Suggest that the client’s mother might be of more help.

4.   Tell him he is not being as effective as he was and that he needs to let someone else take over.

____  50.   The client in labor has moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a −2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority?

1.   Obtain a clean-catch urine specimen.

2.   Apply an internal fetal scalp electrode.

3.   Keep the client on bed rest at this time.

4.   Encourage the husband to remain in the room.

____  51.   The neonatal nurse specialist is describing neonatal care to nursing students. What statement should the specialist include when describing a proper method for preventing heat loss in the neonate?

1.   “After delivery, the newborn is immediately placed in skin-to-skin contact with the father.”

2.   “Immediately after delivery, the newborn is wrapped in the towels used to dry him and placed on the bed beside the mother.”

3.   “If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat.”

4.   “If a radiant-heated unit is used to keep the neonate warm, the neonate is dried, wrapped in a dry blanket, and placed under the radiant heat.”

____  52.   Upon delivery of the newborn, which action most promotes parental attachment?

1.   Placing the newborn under the radiant warmer

2.   Placing the newborn on the maternal abdomen

3.   Taking the newborn to the nursery for the initial assessment

4.   Allowing the mother a chance to rest immediately after delivery

____  53.   A young adolescent is in active labor but did not know that she was pregnant. What is the most important nursing action?

1.   Assess blood pressure and check for proteinuria.

2.   Obtain a Social Services referral to discuss adoption.

3.   Determine who might be the father of the baby for paternity testing.

4.   Ask the client what kind of birthing experience she would like to have.

____  54.   The nurse encounters a woman giving birth at the local shopping mall. What should the nurse do first?

1.   Visualize the perineum.

2.   Apply counterpressure to the perineum.

3.   Ask a bystander for a dry piece of clothing.

4.   Determine if the membranes have ruptured.

____  55.   The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement indicates that further information is required?

1.   “I can take ibuprofen (Motrin) when my perineum starts to hurt.”

2.   “Soaking in the tub will help my mediolateral episiotomy to heal.”

3.   “The tear I have through my rectum is unrelated to my episiotomy.”

4.   “Because I have a midline episiotomy, I should keep my perineum clean.”

____  56.   A client who received a mediolateral episiotomy to facilitate vacuum extraction birth asks what kind of episiotomy was performed. How should the nurse explain the location of the episiotomy?

1.   “It goes straight back toward your rectum.”

2.   “It is from your vagina toward the urethra.”

3.   “It is cut diagonally away from your vagina.”

4.   “It extends from your vagina into your rectum.”

____  57.   A client recovering from delivery asks for another ice pack to place on the site of a midline episiotomy. How should the nurse respond to this request?

1.   “I will get you one right away.”

2.   “You only need to use one ice pack.”

3.   “You need to leave it off for at least 20 minutes and then reapply.”

4.   “I will bring you an extra so that you can change it when you are ready.”

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____  58.   A client’s fetal heart rate has a sinusoidal pattern. What should the nurse consider as being the reason for this pattern? (Select all that apply):

1. Fetal anemia

2. Chronic fetal bleed

3. Severe fetal hypoxia

4. Maternal hypotension

5. Umbilical cord compression

____  59.   The nurse categorizes a client’s fetal heart rate tracing as a level 2. What criteria were used for this categorization? (Select all that apply):

1. Tachycardic baseline.

2. Decelerations lasted longer than 2 minutes.

3. Scalp stimulation did not effect acceleration.

4. Absent variability with recurrent late decelerations.

5. Variable decelerations that slowly return to baseline.

____  60.   Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? (Select all that apply):

1. Early fetal hypoxia

2. Prolonged fetal stimulation

3. Fetal anemia

4. Fetal sleep cycle

5. Infection

____  61.   The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following? (Select all that apply):

1. Maternal dehydration

2. Maternal hyperthyroidism

3. Fetal hypoxia

4. Prematurity

5. Anesthesia or regional analgesia

____  62.   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 which of the following?

(Select all that apply):

1. Maternal hypotension

2. Prolonged umbilical cord compression

3. Fetal dysrhythmia

4. Central nervous system malformation

5. Late fetal asphyxia

____  63.   The nurse is caring for a client 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? (Select all that apply):

1. Provide caring labor support.

2. Administer oxygen via face mask.

3. Change the client's position.

4. Speed up the client's intravenous.

5. Reassure the client and her partner that she is doing fine.

____  64.   While palpating contractions, the nurse determines that a client is in the latent phase of labor. What findings did the nurse use to make this determination? (Select all that apply):

1. Contractions rated as being moderate to strong

2. Contractions rated as being mild to moderate

3. Contractions occur every 6 minutes lasting for 40 seconds

4. Contractions occur every 2 minutes lasting for 50 seconds

5. Contraction occurs every 10 minutes lasting for 30 seconds

____  65.   A client states that her water broke 2 hours ago. What findings should the nurse identify as indications of normal labor? (Select all that apply):

1.   Protein of +1 in urine

2.   Maternal pulse of 160

3.   Blood pressure of 120/80

4.   Odorless, clear fluid on underwear

5.   Fetal heart rate (FHR) of 130 with moderate variability

____  66.   What is the purpose for the client in labor to utilize different breathing techniques? (Select all that apply):

1.   Eliminates pain

2.   A source of relaxation

3.   A source of distraction

4.   Speeds up the delivery process

5.   An increased ability to cope with contractions

____  67.   Ketones are present in a urine specimen of a client in the beginning phases of labor. What should the nurse consider as the reason for this laboratory finding? (Select all that apply):

1. Edema

2. Vomiting

3. Dehydration

4. Preeclampsia

5. Insulin resistance

____  68.   The nurse is caring for a client in the second stage of labor. What assessment findings indicate that birth is imminent? (Select all that apply):

1. Drop in blood pressure

2. Increased bloody show

3. Bulging of the perineum

4. Subjective feeling of faintness

5. Uncontrollable urge to bear down

____  69.   A tiered system of categorizing FHR has been recommended by regulatory agencies. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. These categories include  (Select all that apply):

____  70.   The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patient’s most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration (Select all that apply)?