NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
MULTIPLE CHOICE
1. 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 late in the
contraction, with the nadir of the decelerations occurring after the peak of the contraction. The
nurse’s first priority is to:
a.
change the woman’s position.
b.
notify the care provider.
c.
assist with amnioinfusion.
d.
insert a scalp electrode.
ANS: A
Late decelerations may be caused by maternal supine hypotension syndrome. They usually are
corrected when the woman turns on her side to displace the weight of the gravid uterus from
the vena cava. If the fetus does not respond to primary nursing interventions for late
decelerations, the nurse would continue with subsequent intrauterine resuscitation measures,
including notifying the care provider. An amnioinfusion may be used to relieve pressure on an
umbilical cord that has not prolapsed. The FHR pattern associated with this situation most
likely reveals variable deceleration. A fetal scalp electrode would provide accurate data for
evaluating the well-being of the fetus; however, this is not a nursing intervention that would
alleviate late decelerations, nor is it the nurse’s first priority.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
,NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
PTS: 1 DIF: CognitiNveURLeSvINelG: TABp.pClOicMation
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
2. The nurse caring for the laboring woman should understand that early decelerations are
caused by:
a.
altered fetal cerebral blood flow.
b.
umbilical cord compression.
c.
uteroplacental insufficiency.
d.
spontaneous rupture of membranes.
ANS: A
Early decelerations are the fetus’s response to fetal head compression. Variable decelerations
are associated with umbilical cord compression. Late decelerations are associated with
uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal
heart rate unless the umbilical cord prolapses, which would result in variable or prolonged
bradycardia.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. The nurse providing care for the laboring woman comprehends that accelerations with
fetal movement:
a.
are reassuring.
b.
are caused by umbilical cord compression.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
,NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
c.
warrant close observation.
d.
are caused by uteroplacental insufficiency.
ANS: A
Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are
indications of fetal well-being. Umbilical cord compression results in variable decelerations in
the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant
close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
4. The nurse providing care for the laboring woman realizes that variable fetal heart rate
(FHR) decelerations are caused by:
a.
altered fetal cerebral blood flow.
b. umbilical cord compression.
c.
uteroplacental insufficiency.
d.
fetal hypoxemia.
ANS: B
Variable decelerations can occur any time during the uterine contracting phase and are caused
by compression of the umbilical cord. Altered fetal cerebral blood flow would result in early
decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the
FHR. Fetal hypoxemia would result in tachycardia initially and then bradycardia if hypoxia
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
, NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
continues.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
NURSINGTB.COM
5. The nurse providing care for the laboring woman should understand that late fetal heart
rate (FHR) decelerations are the result of:
a.
altered cerebral blood flow.
b.
umbilical cord compression.
c.
uteroplacental insufficiency.
d.
meconium fluid.
ANS: C
Uteroplacental insufficiency would result in late decelerations in the FHR. Altered fetal
cerebral blood flow would result in early decelerations in the FHR. Umbilical cord
compression would result in variable decelerations in the FHR. Meconium-stained fluid may
or may not produce changes in the fetal heart rate, depending on the gestational age of the
fetus and whether other causative factors associated with fetal distress are present.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. The nurse providing care for the laboring woman should understand that amnioinfusion is
used to treat:
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
Labour|Maternal child nursing care
MULTIPLE CHOICE
1. 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 late in the
contraction, with the nadir of the decelerations occurring after the peak of the contraction. The
nurse’s first priority is to:
a.
change the woman’s position.
b.
notify the care provider.
c.
assist with amnioinfusion.
d.
insert a scalp electrode.
ANS: A
Late decelerations may be caused by maternal supine hypotension syndrome. They usually are
corrected when the woman turns on her side to displace the weight of the gravid uterus from
the vena cava. If the fetus does not respond to primary nursing interventions for late
decelerations, the nurse would continue with subsequent intrauterine resuscitation measures,
including notifying the care provider. An amnioinfusion may be used to relieve pressure on an
umbilical cord that has not prolapsed. The FHR pattern associated with this situation most
likely reveals variable deceleration. A fetal scalp electrode would provide accurate data for
evaluating the well-being of the fetus; however, this is not a nursing intervention that would
alleviate late decelerations, nor is it the nurse’s first priority.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
,NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
PTS: 1 DIF: CognitiNveURLeSvINelG: TABp.pClOicMation
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
2. The nurse caring for the laboring woman should understand that early decelerations are
caused by:
a.
altered fetal cerebral blood flow.
b.
umbilical cord compression.
c.
uteroplacental insufficiency.
d.
spontaneous rupture of membranes.
ANS: A
Early decelerations are the fetus’s response to fetal head compression. Variable decelerations
are associated with umbilical cord compression. Late decelerations are associated with
uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal
heart rate unless the umbilical cord prolapses, which would result in variable or prolonged
bradycardia.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. The nurse providing care for the laboring woman comprehends that accelerations with
fetal movement:
a.
are reassuring.
b.
are caused by umbilical cord compression.
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
,NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
c.
warrant close observation.
d.
are caused by uteroplacental insufficiency.
ANS: A
Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are
indications of fetal well-being. Umbilical cord compression results in variable decelerations in
the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant
close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
4. The nurse providing care for the laboring woman realizes that variable fetal heart rate
(FHR) decelerations are caused by:
a.
altered fetal cerebral blood flow.
b. umbilical cord compression.
c.
uteroplacental insufficiency.
d.
fetal hypoxemia.
ANS: B
Variable decelerations can occur any time during the uterine contracting phase and are caused
by compression of the umbilical cord. Altered fetal cerebral blood flow would result in early
decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the
FHR. Fetal hypoxemia would result in tachycardia initially and then bradycardia if hypoxia
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
, NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
continues.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
NURSINGTB.COM
5. The nurse providing care for the laboring woman should understand that late fetal heart
rate (FHR) decelerations are the result of:
a.
altered cerebral blood flow.
b.
umbilical cord compression.
c.
uteroplacental insufficiency.
d.
meconium fluid.
ANS: C
Uteroplacental insufficiency would result in late decelerations in the FHR. Altered fetal
cerebral blood flow would result in early decelerations in the FHR. Umbilical cord
compression would result in variable decelerations in the FHR. Meconium-stained fluid may
or may not produce changes in the fetal heart rate, depending on the gestational age of the
fetus and whether other causative factors associated with fetal distress are present.
PTS: 1 DIF: Cognitive Level: Knowledge
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. The nurse providing care for the laboring woman should understand that amnioinfusion is
used to treat:
NRSG 113 exam Q&A CH 15:Fatal Assessment During
Labour|Maternal child nursing care
