Obstetrical Nursing – Intrapartum – NCLEX Quiz 1

1. A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion?

Placing the client on complete bed rest

Continuous electronic fetal monitoring

An IV infusion of antibiotics

Placing a code cart at the client’s bedside

Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.

Explanation

Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.

2. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician?

Fetal heart rate of 180 beats per minute

White blood cell count of 12.000

Maternal pulse rate of 85 beats per minute

Hemoglobin of 11.0 g/dL

A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term. a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.

Explanation

A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term. a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.

3. A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted?

The client begins to expel clear vaginal fluid

The contractions are regular

The membranes have ruptured

The cervix is dilated completely

The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.

Explanation

The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.

4. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

Three contractions occurring within a 10-minute period

A fetal heart rate of 90 beats per minute

Adequate resting tone of the uterus palpated between contractions

Increased urinary output

A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to Pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.

Explanation

A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to Pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.

5. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor. the initial nursing assessment is which of the following?

Identifying the types of accelerations

Assessing the baseline fetal heart rate

Determining the frequency of the contractions

Determining the intensity of the contractions

Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess. but not as the first priority.

Explanation

Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess. but not as the first priority.

6. A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table. and the nurse places the client in the:

Trendelenburg’s position with the legs in stirrups

Semi-Fowler position with a pillow under the knees

Prone position with the legs separated and elevated

Supine position with a wedge under the right hip

Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return. cardiac output. and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however. a wedge placed under the right hip provides displacement of the uterus.

Explanation

Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return. cardiac output. and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however. a wedge placed under the right hip provides displacement of the uterus.

7. A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to:

Place the mother in the supine position

Document the findings and continue to monitor the fetal patterns

Administer oxygen via face mask

Increase the rate of Pitocin IV infusion

Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary.Option A: The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava.Option D: An intravenous Pitocin infusion is discontinued when a late deceleration is noted.

Explanation

Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary.Option A: The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava.Option D: An intravenous Pitocin infusion is discontinued when a late deceleration is noted.

8. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate?

Encourage the client’s coach to continue to encourage breathing exercises

Encourage the client to continue pushing with each contraction

Continue monitoring the fetal heart rate

Notify the physician or nurse midwife

A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management. and the physician or nurse-midwife needs to be notified.

Explanation

A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management. and the physician or nurse-midwife needs to be notified.

9. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate?

Document the findings and tell the mother that the monitor indicates fetal well-being

Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen.

Notify the physician or nurse-midwife of the findings.

Reposition the mother and check the monitor for changes in the fetal tracing

Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.

Explanation

Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.

10. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:

Noting if the heart rate is greater than 140 BPM

Placing the diaphragm of the Doppler on the mother’s abdomen

Performing Leopold’s maneuvers first to determine the location of the fetal heart

Palpating the maternal radial pulse while listening to the fetal heart rate

The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar. the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold’s maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.

Explanation

The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar. the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold’s maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.