Maternity Nursing: Intrapartum
NCLEX Practice Questions #7 | 55
Questions
1. Question
A nurse is caring for a client in labor who is receiving Pitocin by IV
infusion to stimulate uterine contractions. Which assessment
finding would indicate to the nurse that the infusion needs to be
discontinued?
o A. Three contractions occurring within a 10-minute
period
o B. Increased urinary output
o C. Adequate resting tone of the uterus palpated
between contractions
o D. A fetal heart rate of 90 beats per minute
Correct Answer: D. A fetal heart rate of 90 beats per
minute
A normal fetal heart rate is 120-160 BPM. Bradycardia or late or
variable decelerations indicate fetal distress and the need to
discontinue Pitocin. The goal of labor augmentation is to achieve
three good-quality contractions in a 10-minute period.
Option A: Pitocin (oxytocin injection) is a natural
hormone that causes the uterus to contract used to
induce labor, strengthen labor contractions during
childbirth, control bleeding after childbirth, or induce
an abortion.
Option B: Oxytocin has an antidiuretic effect and
increases the urinary excretion of AQP2 in humans
whose urinary concentration mechanism is preserved.
Urine volume and free water clearance were
decreased, and urine osmolality was increased by the
administration of oxytocin or dDAVP in the normal
volunteers and CDI patients.
, Option C: In a normal labor, one contraction every
two to three minutes or less than five contractions in a
10 minute period is ideal. A uterus must rest between
contractions, having sufficient uterine resting tone
(soft to the touch), and uterine resting time (about one
minute).
2. 2. Question
A nurse is beginning to care for a client in labor. The physician
has prescribed an IV infusion of Pitocin. The nurse ensures that
which of the following is implemented before initiating the
infusion?
A. Placing the client on complete bed rest
B. Continuous electronic fetal monitoring
C. An IV infusion of antibiotics
D. Placing a code cart at the client’s bedside
Correct Answer: B. Continuous electronic fetal monitoring
Continuous electronic fetal monitoring should be implemented
during an IV infusion of Pitocin. Continuous electronic fetal
monitoring should be performed for a minimum of 20 minutes
before starting oxytocin and should be continued until the baby is
delivered.
Option A: Complete bed rest is not a necessity before
initiating Pitocin infusion. Pitocin is indicated for the
initiation or improvement of uterine contractions,
where this is desirable and considered suitable for
reasons of fetal or maternal concern, in order to
achieve vaginal delivery.
Option C: It is unnecessary to administer IV
antibiotics before Pitocin infusion. Immediately
administer broad-spectrum antibiotics only to patients
with severe postabortion infection.
Option D: A code cart may be placed beside the
client but in case of overdose, contact the Poison
Control Center.
3. 3. Question
, A nurse is monitoring a client in active labor and notes that the
client is having contractions every 3 minutes that last 45
seconds. The nurse notes that the fetal heart rate between
contractions is 100 BPM. Which of the following nursing actions
is most appropriate?
A. Encourage the client’s coach to continue to
encourage breathing exercises.
B. Encourage the client to continue pushing with each
contraction.
C. Continue monitoring the fetal heart rate.
D. Notify the physician or nurse-midwife.
Correct Answer: D. Notify the physician or nurse-midwife.
A normal fetal heart rate is 120-160 beats per minute. Fetal
bradycardia between contractions may indicate the need for
immediate medical management, and the physician or nurse-
midwife needs to be notified.
Option A: Steps can be taken to help the fetus get
more oxygen, such as having the mother change
position. If these procedures do not work, or if further
test results suggest the fetus has a problem, the ob-
gyn or other health care professional may decide to
deliver right away.
Option B: Uterine contractions also may be
monitored with a special tube called an intrauterine
pressure catheter that is inserted through the vagina
into the uterus. Internal monitoring can be used only
after the membranes of the amniotic sac have
ruptured.
Option C: Fetal heart rate monitoring may help detect
changes in the normal heart rate pattern during labor.
If certain changes are detected, steps can be taken to
help treat the underlying problem. Fetal heart rate
monitoring also can help prevent treatments that are
not needed.
4. 4. Question
, A nurse is caring for a client in labor and is monitoring the fetal
heart rate patterns. The nurse notes the presence of episodic
accelerations on the electronic fetal monitor tracing. Which of the
following actions is most appropriate?
A. Document the findings and tell the mother that
the monitor indicates fetal well-being.
B. Take the mother’s vital signs and tell the mother that
bed rest is required to conserve oxygen.
C. Notify the physician or nurse-midwife of the findings.
D. Reposition the mother and check the monitor for
changes in the fetal tracing.
Correct Answer: A. Document the findings and tell the
mother that the monitor indicates fetal well-being.
Accelerations are transient increases in the fetal heart rate that
often accompany contractions or are caused by fetal movement.
Episodic accelerations are thought to be a sign of fetal-well being
and adequate oxygen reserve.
Option B: Inform the mother that they are usually
associated with fetal movement, vaginal
examinations, uterine contractions, umbilical vein
compression, fetal scalp stimulation or even external
acoustic stimulation. The presence of accelerations is
considered a reassuring sign of fetal well-being.
Option C: Accelerations are the basis for the
nonstress test (NST). The presence of at least two
accelerations, each lasting for 15 or more seconds
above baseline and peaking at 15 or more bpm, in a
20-minute period is considered a reactive NST.
Option D: The FHR is controlled by the autonomic
nervous system. The inhibitory influence on the heart
rate is conveyed by the vagus nerve, whereas
excitatory influence is conveyed by the sympathetic
nervous system. Progressive vagal dominance occurs
as the fetus approaches term and, after birth, results
in a gradual decrease in the baseline FHR. Stimulation
of the peripheral nerves of the fetus by its own activity
NCLEX Practice Questions #7 | 55
Questions
1. Question
A nurse is caring for a client in labor who is receiving Pitocin by IV
infusion to stimulate uterine contractions. Which assessment
finding would indicate to the nurse that the infusion needs to be
discontinued?
o A. Three contractions occurring within a 10-minute
period
o B. Increased urinary output
o C. Adequate resting tone of the uterus palpated
between contractions
o D. A fetal heart rate of 90 beats per minute
Correct Answer: D. A fetal heart rate of 90 beats per
minute
A normal fetal heart rate is 120-160 BPM. Bradycardia or late or
variable decelerations indicate fetal distress and the need to
discontinue Pitocin. The goal of labor augmentation is to achieve
three good-quality contractions in a 10-minute period.
Option A: Pitocin (oxytocin injection) is a natural
hormone that causes the uterus to contract used to
induce labor, strengthen labor contractions during
childbirth, control bleeding after childbirth, or induce
an abortion.
Option B: Oxytocin has an antidiuretic effect and
increases the urinary excretion of AQP2 in humans
whose urinary concentration mechanism is preserved.
Urine volume and free water clearance were
decreased, and urine osmolality was increased by the
administration of oxytocin or dDAVP in the normal
volunteers and CDI patients.
, Option C: In a normal labor, one contraction every
two to three minutes or less than five contractions in a
10 minute period is ideal. A uterus must rest between
contractions, having sufficient uterine resting tone
(soft to the touch), and uterine resting time (about one
minute).
2. 2. Question
A nurse is beginning to care for a client in labor. The physician
has prescribed an IV infusion of Pitocin. The nurse ensures that
which of the following is implemented before initiating the
infusion?
A. Placing the client on complete bed rest
B. Continuous electronic fetal monitoring
C. An IV infusion of antibiotics
D. Placing a code cart at the client’s bedside
Correct Answer: B. Continuous electronic fetal monitoring
Continuous electronic fetal monitoring should be implemented
during an IV infusion of Pitocin. Continuous electronic fetal
monitoring should be performed for a minimum of 20 minutes
before starting oxytocin and should be continued until the baby is
delivered.
Option A: Complete bed rest is not a necessity before
initiating Pitocin infusion. Pitocin is indicated for the
initiation or improvement of uterine contractions,
where this is desirable and considered suitable for
reasons of fetal or maternal concern, in order to
achieve vaginal delivery.
Option C: It is unnecessary to administer IV
antibiotics before Pitocin infusion. Immediately
administer broad-spectrum antibiotics only to patients
with severe postabortion infection.
Option D: A code cart may be placed beside the
client but in case of overdose, contact the Poison
Control Center.
3. 3. Question
, A nurse is monitoring a client in active labor and notes that the
client is having contractions every 3 minutes that last 45
seconds. The nurse notes that the fetal heart rate between
contractions is 100 BPM. Which of the following nursing actions
is most appropriate?
A. Encourage the client’s coach to continue to
encourage breathing exercises.
B. Encourage the client to continue pushing with each
contraction.
C. Continue monitoring the fetal heart rate.
D. Notify the physician or nurse-midwife.
Correct Answer: D. Notify the physician or nurse-midwife.
A normal fetal heart rate is 120-160 beats per minute. Fetal
bradycardia between contractions may indicate the need for
immediate medical management, and the physician or nurse-
midwife needs to be notified.
Option A: Steps can be taken to help the fetus get
more oxygen, such as having the mother change
position. If these procedures do not work, or if further
test results suggest the fetus has a problem, the ob-
gyn or other health care professional may decide to
deliver right away.
Option B: Uterine contractions also may be
monitored with a special tube called an intrauterine
pressure catheter that is inserted through the vagina
into the uterus. Internal monitoring can be used only
after the membranes of the amniotic sac have
ruptured.
Option C: Fetal heart rate monitoring may help detect
changes in the normal heart rate pattern during labor.
If certain changes are detected, steps can be taken to
help treat the underlying problem. Fetal heart rate
monitoring also can help prevent treatments that are
not needed.
4. 4. Question
, A nurse is caring for a client in labor and is monitoring the fetal
heart rate patterns. The nurse notes the presence of episodic
accelerations on the electronic fetal monitor tracing. Which of the
following actions is most appropriate?
A. Document the findings and tell the mother that
the monitor indicates fetal well-being.
B. Take the mother’s vital signs and tell the mother that
bed rest is required to conserve oxygen.
C. Notify the physician or nurse-midwife of the findings.
D. Reposition the mother and check the monitor for
changes in the fetal tracing.
Correct Answer: A. Document the findings and tell the
mother that the monitor indicates fetal well-being.
Accelerations are transient increases in the fetal heart rate that
often accompany contractions or are caused by fetal movement.
Episodic accelerations are thought to be a sign of fetal-well being
and adequate oxygen reserve.
Option B: Inform the mother that they are usually
associated with fetal movement, vaginal
examinations, uterine contractions, umbilical vein
compression, fetal scalp stimulation or even external
acoustic stimulation. The presence of accelerations is
considered a reassuring sign of fetal well-being.
Option C: Accelerations are the basis for the
nonstress test (NST). The presence of at least two
accelerations, each lasting for 15 or more seconds
above baseline and peaking at 15 or more bpm, in a
20-minute period is considered a reactive NST.
Option D: The FHR is controlled by the autonomic
nervous system. The inhibitory influence on the heart
rate is conveyed by the vagus nerve, whereas
excitatory influence is conveyed by the sympathetic
nervous system. Progressive vagal dominance occurs
as the fetus approaches term and, after birth, results
in a gradual decrease in the baseline FHR. Stimulation
of the peripheral nerves of the fetus by its own activity
