Maternity EXAM-3M – Clovis Community College Chapter 18 1. What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern? a. Altered fetal cerebral blood flow b. Umbilical cord compression c
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Maternity EXAM-3M – Clovis Community College Chapter 18 1. What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Spontaneous rupture of membranes ANS: A Early decelerations are the fetus’ response to fetal head compression; these are considered benign, and interventions are not necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. 2. Which clinical finding or intervention might be considered the rationale for fetal tachycardia to occur? a. Maternal fever b. Umbilical cord prolapse c. Regional anesthesia d. Magnesium sulfate administration ANS: A Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. 3. While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the FHR for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. What is the nurse’s first priority? a. Change the woman’s position. b. Notify the health care provider. c. Assist with amnioinfusion d. Insert a scalp electrode. ANS: A Late FHR decelerations may be caused by maternal supine hypotension syndrome. These decelerations are usually corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, then the nurse should continue with subsequent intrauterine resuscitation measures and notify the health care provider. 4. What is the most likely cause for variable FHR decelerations? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Fetal hypoxemia ANS: B Variable FHR decelerations can occur at any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. 5. The nurse providing care for a high-risk laboring woman is alert for late FHR decelerations. Which clinical finding might be the cause for these late decelerations? a. Altered cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Meconium fluid ANS: C Uteroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood flow results in early FHR decelerations. Umbilical cord compression results in variable FHR decelerations. Meconium-stained fluid may or may not produce changes in the FHR, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present. 6. Which alteration in the FHR pattern would indicate the potential need for an amnioinfusion? a. Variable decelerations b. Late decelerations c. Fetal bradycardia d. Fetal tachycardia ANS: A Amnioinfusion is used during labor to either dilute meconium-stained amniotic fluid or supplement the amount of amniotic fluid to reduce the severity of variable FHR decelerations caused by cord compression. Late decelerations are unresponsive to amnioinfusion. Amnioinfusion is not appropriate for the treatment of fetal bradycardia and has no bearing on fetal tachycardia. 7. Which FHR finding is the most concerning to the nurse who is providing care to a laboring client? a. Accelerations with fetal movement b. Early decelerations c. Average FHR of 126 beats per minute d. Late decelerations ANS: D Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. Late FHR decelerations are considered ominous if they are persistent and left uncorrected. Accelerations with fetal movement are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they are not generally a concern during normal labor. An FHR finding of 126 beats per minute is normal and not a concern. 8. What three measures should the nurse implement to provide intrauterine resuscitation? a. Call the provider, reposition the mother, and perform a vaginal examination. b. Turn the client onto her side, provide oxygen (O2) via face mask, and increase intravenous (IV) fluids. c. Administer O2 to the mother, increase IV fluids, and notify the health care provider. d. Perform a vaginal examination, reposition the mother, and provide O2 via face mask. ANS: B Basic interventions for the management of any abnormal FHR pattern include administering O2 via a nonrebreather face mask at a rate of 8 to 10 L/min, assisting the woman onto a side-lying (lateral) position, and increasing blood volume by increasing the rate of the primary IV infusion. The purpose of these interventions is to improve uterine blood flow and intervillous space blood flow and to increase maternal oxygenation and cardiac output. The term intrauterine resuscitation is sometimes used to refer to these interventions. If these interventions do not quickly resolve the abnormal FHR issue, then the primary provider should be immediately notified. 9. The nurse who provides care to clients in labor must have a thorough understanding of the physiologic processes of maternal hypotension. Which outcome might occur if the interventions for maternal hypotension are inadequate? a. Early FHR decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes ANS: C Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early FHR decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension. 10. What are the legal responsibilities of the perinatal nurses? a. Correctly interpreting FHR patterns, initiating appropriate nursing interventions, and documenting the outcomes b. Greeting the client on arrival, assessing her status, and starting an IV line c. Applying the external fetal monitor and notifying the health care provider d. Ensuring that the woman is comfortable ANS: A Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions. Greeting the client on arrival, assessing her, and starting an IV line are activities that should be performed when any client arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions. Applying the external fetal monitor and notifying the health care provider is a nursing function that is part of the standard of care for all obstetric clients and falls within the registered nurse’s scope of practice. Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable. 11. The perinatal nurse realizes that an FHR that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with which condition? a. Hypotension b. Cord compression c. Maternal drug use d. Hypoxemia ANS: D Nonreassuring FHR patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Variable FHR decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia. - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -24. What is a maternal indication for the use of vacuum-assisted birth? a. Wide pelvic outlet b. Maternal exhaustion c. History of rapid deliveries d. Failure to progress past station 0 ANS: B A mother who is exhausted may be unable to assist with the expulsion of the fetus. The client with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum-assisted birth. DIF: Cognitive Level: Understand REF: p. 786 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 25. Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant? a. Assessing the infant for signs of trauma b. Administering prophylactic antibiotic agents to the infant c. Applying a cold pack to the infant’s scalp d. Measuring the circumference of the infant’s head ANS: A The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would place the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment. DIF: Cognitive Level: Apply REF: p. 788 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE 1. The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues alert the nurse that the woman is experiencing uterine hyperstimulation? (Select all that apply.) a. Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency b. Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency c. Uterine tone <20 mm Hg d. Uterine tone >20 mm Hg e. Increased uterine activity accompanied by a nonreassuring FHR and pattern ANS: B, D, E Uterine contractions that occur less frequently than 2 minutes apart and last longer than 90 seconds, a uterine tone over 20 mm Hg, and a nonreassuring FHR and pattern are indications of uterine hyperstimulation with oxytocin administration. Uterine contractions that occur more frequently than 2 minutes apart and last less than 90 seconds are the expected goal of oxytocin induction. A uterine tone less than 20 mm Hg is normal. DIF: Cognitive Level: Analyze REF: p. 785 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 2. What are the complications and risks associated with cesarean births? (Select all that apply.) a. Pulmonary edema b. Wound dehiscence c. Hemorrhage d. Urinary tract infections e. Fetal injuries ANS: A, B, C, D, E Pulmonary edema, wound dehiscence, hemorrhage, urinary tract infections, and fetal injuries are possible complications and risks associated with cesarean births. DIF: Cognitive Level: Understand REF: p. 790 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 3. Women who are obese are at risk for several complications during pregnancy and birth. Which of these would the nurse anticipate with an obese client? (Select all that apply.) a. Thromboembolism b. Cesarean birth c. Wound infection d. Breech presentation e. Hypertension ANS: A, B, C, E A breech presentation is not a complication of pregnancy or birth for the client who is obese. Venous thromboembolism is a known risk for obese women. Therefore, the use of thromboembolism-deterrent (TED) hose and sequential compression devices may help decrease the chance for clot formation. Women should also be encouraged to ambulate as soon as possible. In addition to having an increased risk for complications with a cesarean birth, in general, obese women are also more likely to require an emergency cesarean birth. Many obese women have a pannus (i.e., large roll of abdominal fat) that overlies a lower transverse incision made just above the pubic area. The pannus causes the area to remain moist, which encourages the development of infection. Obese women are more likely to begin pregnancy with comorbidities such as hypertension and type 2 diabetes. DIF: Cognitive Level: Analyze REF: p. 778 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. The induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. What are appropriate indications for induction? (Select all that apply?) a. Rupture of membranes at or near term b. Convenience of the woman or her physician c. Chorioamnionitis (inflammation of the amniotic sac) d. Postterm pregnancy e. Fetal death ANS: A, C, D, E The conditions listed are all acceptable indications for induction. Other conditions include intrauterine growth restriction (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks of completed gestation. DIF: Cognitive Level: Apply REF: p. 790 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 5. Indications for a primary cesarean birth are often nonrecurring. Therefore, a woman who has had a cesarean birth with a low transverse scar may be a candidate for vaginal birth after cesarean (VBAC). Which clients would beless likely to have a successful VBAC? (Select all that apply.) a. Lengthy interpregnancy interval b. African-American race c. Delivery at a rural hospital d. Estimated fetal weight <4000 g e. Maternal obesity (BMI >30) ANS: B, C, E
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