Obstetrical Nursing – Intrapartum – NCLEX Quiz 4

1. The nurse observes the client's amniotic fluid and decides that it appears normal. because it is:

Clear and dark amber in color

Milky. greenish yellow. containing shreds of mucus

Clear. almost colorless. and containing little white specks

Cloudy. greenish-yellow. and containing little white specks

By 36 weeks gestation. normal amniotic fluid is colorless with small particles of vernix caseosa present.

Explanation

By 36 weeks gestation. normal amniotic fluid is colorless with small particles of vernix caseosa present.

2. A client is admitted to the birthing suite in early active labor. The priority nursing intervention on the admission of this client would be:

Auscultating the fetal heart

Taking an obstetric history

Asking the client when she last ate

Ascertaining whether the membranes were ruptured

Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating. immediate intervention is required.

Explanation

Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating. immediate intervention is required.

3. When monitoring the fetal heart rate of a client in labor. the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:

An acceleration

An early elevation

A sonographic motion

A tachycardic heart rate

An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.

Explanation

An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.

4. After doing Leopold's maneuvers. the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones. the Doppler is placed:

Above the umbilicus at the midline

Above the umbilicus on the left side

Below the umbilicus on the right side

Below the umbilicus near the left groin

Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting). the back would be below the umbilicus and on the right side.

Explanation

Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting). the back would be below the umbilicus and on the right side.

5. The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction:

Until the time it is completely over

To the end of a second contraction

To the beginning of the next contraction

Until the time that the uterus becomes very firm

This is the way to determine the frequency of the contractions

Explanation

This is the way to determine the frequency of the contractions

6. A client who is gravida 1. para 0 is admitted in labor. Her cervix is 100% effaced. and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is:

Not yet engaged

Entering the pelvic inlet

Below the ischial spines

Visible at the vaginal opening

A station of +1 indicates that the fetal head is 1 cm below the ischial spines.

Explanation

A station of +1 indicates that the fetal head is 1 cm below the ischial spines.

7. The breathing technique that the mother should be instructed to use as the fetus' head is crowning is:

Blowing

Slow chest

Shallow

Accelerated-decelerated

Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.

Explanation

Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.

8. When examining the fetal monitor strip after the rupture of the membranes in a laboring client. the nurse notes variable decelerations in the fetal heart rate. The nurse should:

Stop the oxytocin infusion

Change the client’s position

Prepare for immediate delivery

Take the client’s blood pressure

Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.

Explanation

Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.

9. A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:

Breech

Transverse

Occiput anterior

Occiput posterior

A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.

Explanation

A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.

10. At 38 weeks gestation. a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:

Discontinue the catheter. if the reading is not above 80%

Discontinue the catheter. if the reading does not go below 30%

Advance the catheter until the reading is above 90% and continue monitoring

Reposition the catheter. recheck the reading. and if it is 55%. keep monitoring

Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.

Explanation

Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.