Which of the following is a characteristic of a reassuring fetal heart rate pattern?
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Solution
Acceleration of FHR with fetal movements
Accelerations with movement are normal.
Options A, B, and C: These assessments indicate ominous findings on the fetal heart monitor.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
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Solution
Reposition the client
The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated.
Option A: Notifying the physician might be necessary but not before turning the client to her side.
Option B: Starting an IV is not necessary at this time.
Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied incorrectly.
As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
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Solution
There is uteroplacental insufficiency.
This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen.
Option A: Has no relation to the readings.
Option B: Compressed umbilical cord results in a variable deceleration.
Option C: A vagal response is indicative of an early deceleration.
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
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Solution
Potential fluid volume deficit related to decreased fluid intake
Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit.
Option A: Impaired gas exchange related to hyperventilation would be indicated during the transition phase.
Options B and C: Impaired physical mobility and fluid volume deficit are not correct in relation to the stem.
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
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Solution
The membranes are still intact.
The nurse decides to apply an external monitor because the membranes are intact.
Options A, C, and D: The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
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Solution
Apply the fetal heart monitor
Applying a fetal heart monitor is the correct action at this time.
Options A and C: There is no need to prepare for a Caesarean section or to place the client in Genupectoral position (knee-chest).
Option D: There is no need for an ultrasound based on the finding.
In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
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Solution
Progressive cervical dilation
The expected effect of Pitocin is cervical dilation.
Option A: Pitocin causes more intense contractions, which can increase the pain.
Option B: Cervical effacement is caused by pressure on the presenting part.
Option C: Infrequent contractions is opposite the action of Pitocin.
The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:
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Solution
Turn the client to her left side
The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen.
Option A: Repositioning the monitor is not indicated at this time.
Option C: Asking the client to ambulate is not the best action for clients experiencing bradycardia.
Option D: There is no data to indicate the need to move the client to the delivery room at this time.
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
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Solution
“When can I get my epidural?”
Dilation of 2 cm marks the end of the latent phase of labor.
Option A is a vague answer.
Option B indicates the end of the first stage of labor.
Option C indicates the transition phase.
A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?
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Solution
A moderate amount of straw-colored fluid
An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless.
Options A and C: Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium.
Option D: If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord and would need to be reported immediately.