PERRY’S MATERNAL CHILD
NURSING CARE ;( FETAL
ASSESSMENT DURING LABOR)
QUESTIONS AND THEIR 100%
REVIEWED ANSWERS
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.
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.
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.
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.
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
continues.
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
NURSING CARE ;( FETAL
ASSESSMENT DURING LABOR)
QUESTIONS AND THEIR 100%
REVIEWED ANSWERS
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.
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.
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.
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.
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
continues.
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
