While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate during the contraction's peak, with the nadir of the decelerations occurring when the contraction end. The nurse's first priority is to:
Select one:

Insert a scalp electrode.

Notify the care provider.

Assist with amnioinfusion.

Reposition the patient.

Answer and Explanation

The Correct Answer is D

a. A scalp electrode is not indicated unless there is a problem with the external monitor tracing or if further assessment of the fetal heart rate variability is needed.
b. This is important but repositioning the patient is the priority.

c. Amnioinfusion is only done if repositioning the patient does not resolve the late decelerations.

d. The nurse is observing late decelerations of the fetal heart rate, which indicate uteroplacental insufficiency and fetal hypoxia. The nurse's first priority is to reposition the patient to improve placental blood flow and oxygen delivery to the fetus. Repositioning can be done by turning the patient to her side, elevating her legs, or placing a wedge under her hip.

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Correct Answer is D

Explanation

a. This is not the correct response for this situation.

b. This is not the correct response for this situation.

c. This is not the correct response for this situation.

d. An ultrasound is typically performed prior to an amniocentesis to identify the location of the placenta and fetus to avoid injury during the procedure.

A. Perform a venipuncture for hemoglobin and hematocrit levels B. Place clean disposable pads to collect any drainage C. Monitor uterine contractions D. Asses fetal heart rate (FHR) and maternal vital signs

Correct Answer is D

Explanation

a. While this is important, it is not the priority when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy.
b. This is important for managing the bleeding but is not the priority.
c. Monitoring uterine contractions is important, but assessing fetal heart rate (FHR) and maternal vital signs is the priority to determine the status of the fetus and mother.
d. Bleeding in late pregnancy can indicate placental abruption, which is a life- threatening condition for both the mother and the fetus. The nurse should monitor the FHR and maternal vital signs to assess the severity of the bleeding and the fetal and maternal well-being.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy ( 37 weeks) is to: Select one:

Correct Answer is D

Explanation

A nurse is planning to teach couples about the physiology of the sex act. What correct information will the nurse provide? Select one:

The nurse is administering Terbutaline (Brethine) to a pregnant woman to stop preterm labor. Which finding indicates an adverse reaction and the Physician must be notified? Select one:

Which fetal heart rate (FHR) finding would concern the nurse during labor? Select one:

A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority? Select one:

A nurse is instructing a female client about how to check the basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times?

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) baseline is around 130 beats/min, with four accelerations in 20 minutes, lasting 20 seconds each and the FHR increased more than 25 bpm. Which of the following actions should the nurse perform?