1
Introductory Maternity and Pediatric Nursing 4th
Edition Hatfield Test Bank.
Exam Year: 2026/2027
Status: GRADED A DOCS
Domain 1: Antepartum, Intrapartum & Postpartum Nursing (30 Questions)
1. The nurse is monitoring a client in labor who is experiencing late decelerations on
the fetal heart rate monitor. Which of the following is the priority nursing
intervention?
A. Increase the intravenous fluid rate.
B. Administer a prescribed tocolytic medication.
C. Turn the mother to her left side, discontinue oxytocin, and apply oxygen.
D. Prepare for an immediate amnioinfusion.
[CORRECT] C. Turn the mother to her left side, discontinue oxytocin, and apply
oxygen.
Rationale: Late decelerations indicate uteroplacental insufficiency. The immediate
intervention is to maximize oxygenation to the fetus and reduce uterine pressure on
the descending aorta. This is achieved by placing the mother in the left lateral
position (to improve perfusion), stopping oxytocin (to reduce uterine irritability),
and applying oxygen via a non-rebreather mask.
, 2
2. A nurse observes late decelerations on the fetal monitor. The client is currently
lying in a supine position. What is the physiological rationale for turning the client
to the left side?
A. It increases renal perfusion and reduces edema.
B. It relieves pressure on the inferior vena cava and improves placental blood flow.
C. It facilitates the descent of the fetal presenting part.
D. It reduces the risk of maternal hypotension caused by spinal anesthesia.
[CORRECT] B. It relieves pressure on the inferior vena cava and improves placental
blood flow.
Rationale: The supine position allows the heavy gravid uterus to compress the
inferior vena cava and descending aorta, decreasing cardiac return and uterine
perfusion. Turning the client to the left side relieves this compression, restoring
blood flow to the placenta and oxygen delivery to the fetus, which resolves late
decelerations caused by supine hypotension.
3. The laboring client has an oxytocin (Pitocin) infusion running. The fetal heart rate
tracing shows repetitive late decelerations. What is the nurse's immediate action
regarding the oxytocin?
A. Increase the rate to strengthen contractions and shorten labor.
B. Decrease the rate by half and reassess in 10 minutes.
C. Discontinue the oxytocin infusion immediately.
D. Administer a bolus of IV fluids to potentiate the oxytocin.
[CORRECT] C. Discontinue the oxytocin infusion immediately.
, 3
Rationale: Oxytocin stimulates uterine contractions, which can further compromise
placental perfusion if uteroplacental insufficiency (indicated by late decelerations) is
present. The priority intervention is to stop the uterotonic agent immediately to
reduce the frequency and intensity of contractions and allow for placental recovery.
4. Following a cesarean section, the nurse notes the fetal heart rate tracing shows
late decelerations in the recovery room. The client is not on oxytocin. Which
intervention is most appropriate?
A. Turn the client to the left side and apply oxygen at 10 L/min via non-rebreather
mask.
B. Check the client’s epidural site for leakage.
C. Administer a dose of terbutaline subcutaneously.
D. Encourage the client to deep breathe and cough.
[CORRECT] A. Turn the client to the left side and apply oxygen at 10 L/min via non-
rebreather mask.
Rationale: Late decelerations require immediate intervention to improve fetal
oxygenation regardless of the setting (OR or recovery). Repositioning to the left
side relieves aortocaval compression and administering high-flow oxygen
maximizes the oxygen content of the maternal blood reaching the fetus.
5. (SATA) The nurse identifies late decelerations on the fetal monitor. Which of the
following actions should the nurse take? Select all that apply.
A. Turn the client to the left lateral position.
B. Discontinue the oxytocin infusion if running.
, 4
C. Apply oxygen via a non-rebreather mask at 8-10 L/min.
D. Perform a vaginal examination to check cervical dilation.
E. Document the finding and continue to monitor.
[CORRECT] A, B, C
Rationale: The standard nursing response to late decelerations (uteroplacental
insufficiency) involves the trio of interventions: repositioning (left side), stopping
uterine stimulants (oxytocin), and administering oxygen. Checking dilation or
continuing to monitor without intervention delays necessary treatment for fetal
hypoxia.
6. A client is in active labor. The nurse notes the fetal heart rate baseline is 145 bpm
with late decelerations occurring with the peak of every contraction. The nurse
turns the client to the left side and applies oxygen. What is the next priority nursing
action?
A. Palpate the fundus for firmness.
B. Check the maternal blood pressure.
C. Call the healthcare provider to report the finding and interventions taken.
D. Prepare for an emergency cesarean section.
[CORRECT] C. Call the healthcare provider to report the finding and interventions
taken.
Rationale: After implementing immediate nursing interventions to correct late
decelerations, the nurse must notify the provider so that further medical
management (e.g., fluid resuscitation, amnioinfusion, or delivery) can be initiated if
the pattern does not resolve.
Introductory Maternity and Pediatric Nursing 4th
Edition Hatfield Test Bank.
Exam Year: 2026/2027
Status: GRADED A DOCS
Domain 1: Antepartum, Intrapartum & Postpartum Nursing (30 Questions)
1. The nurse is monitoring a client in labor who is experiencing late decelerations on
the fetal heart rate monitor. Which of the following is the priority nursing
intervention?
A. Increase the intravenous fluid rate.
B. Administer a prescribed tocolytic medication.
C. Turn the mother to her left side, discontinue oxytocin, and apply oxygen.
D. Prepare for an immediate amnioinfusion.
[CORRECT] C. Turn the mother to her left side, discontinue oxytocin, and apply
oxygen.
Rationale: Late decelerations indicate uteroplacental insufficiency. The immediate
intervention is to maximize oxygenation to the fetus and reduce uterine pressure on
the descending aorta. This is achieved by placing the mother in the left lateral
position (to improve perfusion), stopping oxytocin (to reduce uterine irritability),
and applying oxygen via a non-rebreather mask.
, 2
2. A nurse observes late decelerations on the fetal monitor. The client is currently
lying in a supine position. What is the physiological rationale for turning the client
to the left side?
A. It increases renal perfusion and reduces edema.
B. It relieves pressure on the inferior vena cava and improves placental blood flow.
C. It facilitates the descent of the fetal presenting part.
D. It reduces the risk of maternal hypotension caused by spinal anesthesia.
[CORRECT] B. It relieves pressure on the inferior vena cava and improves placental
blood flow.
Rationale: The supine position allows the heavy gravid uterus to compress the
inferior vena cava and descending aorta, decreasing cardiac return and uterine
perfusion. Turning the client to the left side relieves this compression, restoring
blood flow to the placenta and oxygen delivery to the fetus, which resolves late
decelerations caused by supine hypotension.
3. The laboring client has an oxytocin (Pitocin) infusion running. The fetal heart rate
tracing shows repetitive late decelerations. What is the nurse's immediate action
regarding the oxytocin?
A. Increase the rate to strengthen contractions and shorten labor.
B. Decrease the rate by half and reassess in 10 minutes.
C. Discontinue the oxytocin infusion immediately.
D. Administer a bolus of IV fluids to potentiate the oxytocin.
[CORRECT] C. Discontinue the oxytocin infusion immediately.
, 3
Rationale: Oxytocin stimulates uterine contractions, which can further compromise
placental perfusion if uteroplacental insufficiency (indicated by late decelerations) is
present. The priority intervention is to stop the uterotonic agent immediately to
reduce the frequency and intensity of contractions and allow for placental recovery.
4. Following a cesarean section, the nurse notes the fetal heart rate tracing shows
late decelerations in the recovery room. The client is not on oxytocin. Which
intervention is most appropriate?
A. Turn the client to the left side and apply oxygen at 10 L/min via non-rebreather
mask.
B. Check the client’s epidural site for leakage.
C. Administer a dose of terbutaline subcutaneously.
D. Encourage the client to deep breathe and cough.
[CORRECT] A. Turn the client to the left side and apply oxygen at 10 L/min via non-
rebreather mask.
Rationale: Late decelerations require immediate intervention to improve fetal
oxygenation regardless of the setting (OR or recovery). Repositioning to the left
side relieves aortocaval compression and administering high-flow oxygen
maximizes the oxygen content of the maternal blood reaching the fetus.
5. (SATA) The nurse identifies late decelerations on the fetal monitor. Which of the
following actions should the nurse take? Select all that apply.
A. Turn the client to the left lateral position.
B. Discontinue the oxytocin infusion if running.
, 4
C. Apply oxygen via a non-rebreather mask at 8-10 L/min.
D. Perform a vaginal examination to check cervical dilation.
E. Document the finding and continue to monitor.
[CORRECT] A, B, C
Rationale: The standard nursing response to late decelerations (uteroplacental
insufficiency) involves the trio of interventions: repositioning (left side), stopping
uterine stimulants (oxytocin), and administering oxygen. Checking dilation or
continuing to monitor without intervention delays necessary treatment for fetal
hypoxia.
6. A client is in active labor. The nurse notes the fetal heart rate baseline is 145 bpm
with late decelerations occurring with the peak of every contraction. The nurse
turns the client to the left side and applies oxygen. What is the next priority nursing
action?
A. Palpate the fundus for firmness.
B. Check the maternal blood pressure.
C. Call the healthcare provider to report the finding and interventions taken.
D. Prepare for an emergency cesarean section.
[CORRECT] C. Call the healthcare provider to report the finding and interventions
taken.
Rationale: After implementing immediate nursing interventions to correct late
decelerations, the nurse must notify the provider so that further medical
management (e.g., fluid resuscitation, amnioinfusion, or delivery) can be initiated if
the pattern does not resolve.
