A nurse is caring for a client who is pregnant.

The client’s vital signs are as follows: Temperature 37.2°C (98.9°F), Pulse rate 80/min, Respiratory rate 16/min, Blood Pressure 120/69 mm Hg. What should the nurse monitor next?

Fetal heart rate.

Uterine contractions.

Amniotic fluid levels.

Cervical dilation.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Monitoring the fetal heart rate is the next appropriate action. The fetal heart rate provides crucial information about the fetus’s well-being and can help identify any potential issues that may need further intervention.
Choice B rationale
Monitoring uterine contractions is important, but in this scenario, the client’s vital signs are stable, and there is no indication of labor. Therefore, monitoring the fetal heart rate takes precedence.
Choice C rationale
Amniotic fluid levels are important to monitor, but they are typically assessed through ultrasound rather than immediate bedside monitoring. The fetal heart rate provides more immediate information about the fetus’s condition.
Choice D rationale
Cervical dilation is relevant during labor, but there is no indication that the client is in labor based on the provided vital signs. Monitoring the fetal heart rate is more pertinent in this situation.

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Correct Answer is A

Explanation

Choice A rationale
Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia. They occur after the peak of a contraction and indicate that the fetus is not receiving enough oxygen. This requires immediate intervention to improve fetal oxygenation and prevent fetal distress.
Choice B rationale
Variability in fetal heart rate of 12 bpm is considered moderate variability, which is a reassuring sign of fetal well-being. It indicates that the fetus has a healthy autonomic nervous system and is not in distress.
Choice C rationale
Accelerations in fetal heart rate are also a reassuring sign. They indicate that the fetus is well-oxygenated and responding appropriately to stimuli. No intervention is needed for accelerations.
Choice D rationale
A baseline fetal heart rate of 140 bpm is within the normal range (110-160 bpm) and does not indicate any immediate concern. It is a sign of a healthy, well-oxygenated fetus.

A. The presenting part is 2 cm below the ischial spines. B. The presenting part is 2 cm above the ischial spines. C. The presenting part is at the level of the ischial spines. D. The presenting part is 2 cm below the cervix.

Correct Answer is B

Explanation

Choice A rationale
The presenting part being 2 cm below the ischial spines would be documented as +2 station, indicating that the fetal head is descending well into the pelvis.
Choice B rationale
The presenting part being 2 cm above the ischial spines is correctly documented as -2 station. This indicates that the fetal head is still relatively high in the pelvis and has not yet descended to the level of the ischial spines.
Choice C rationale
The presenting part being at the level of the ischial spines is documented as 0 station. This is the midpoint of the pelvis and indicates that the fetal head is engaged.
Choice D rationale
The presenting part being 2 cm below the cervix is not a standard way to describe fetal station. Station is measured relative to the ischial spines, not the cervix.

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A nurse is caring for a client who is pregnant. The client’s vital signs are as follows: Temperature 37.2°C (98.9°F), Pulse rate 80/min, Respiratory rate 16/min, Blood Pressure 120/69 mm Hg. What should the nurse monitor next?

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Naxlex Comprehensive Predictor Exams

When interpreting a fetal monitoring tracing, which of the following findings would require the nurse to intervene?

Correct Answer is A

Explanation

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as -2 station. Which of the following interpretations of this finding should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the first stage of labor. Which of the following best describes the pathophysiology of early decelerations?

The nurse preceptor is teaching about the physiology of the fetal heart rate (FHR) pattern. Which statement by the student indicates a lack of understanding?

The labor and delivery nurse tells her client she has completed stage 1 of labor. Which of the following statements by the student nurse indicates confusion about the stages of labor?

The labor and delivery nurse is caring for a client in active labor. The nurse notes the fetal heart rate baseline is 175 bpm, moderate variability, accelerations are absent and no decelerations noted. How should the nurse describe this tracing to the medical provider?

A nurse is creating the plan of care for a client in active labor. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client’s umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

A nurse is caring for a client who is pregnant.

The client’s vital signs are as follows: Temperature 37.2°C (98.9°F), Pulse rate 80/min, Respiratory rate 16/min, Blood Pressure 120/69 mm Hg. What should the nurse monitor next?