Chapter 18: Fetal Assessment During Labor
MULTIPLE CHOICE
1. What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?
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’ response to fetal head compression; these are considered
benign, and interventions are not necessary. Variable decelerations are associated with
umbilical cord compression. Late decelerations are associated with uteroplacental
insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the
umbilical cord prolapses, which would result in variable or prolonged bradycardia.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
2. Which clinical finding or intervention might be considered the rationale for fetal tachycardia
to occur?
a. Maternal fever
b. Umbilical cord prolapseNURSINGTB.COM
c. Regional anesthesia
d. Magnesium sulfate administration
ANS: A
Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result
from maternal or fetal infection. Umbilical cord prolapse, regional anesthesia, and the
administration of magnesium sulfate will each more likely result in fetal bradycardia, not
tachycardia.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
3. 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.
What is the nurse’s first priority?
a. Change the woman’s position.
b. Notify the health care provider.
c. Assist with amnioinfusion
d. Insert a scalp electrode.
ANS: A
, Late FHR decelerations may be caused by maternal supine hypotension syndrome. These
decelerations are usually corrected when the woman turns onto 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, then the nurse should continue with subsequent
intrauterine resuscitation measures and notify the health 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 will reveal variable decelerations. Although
a fetal scalp electrode will provide accurate data for evaluating the well-being of the fetus, it
is not a nursing intervention that will alleviate late decelerations nor is it the nurse’s first
priority.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
4. What is the most likely cause for variable fetal heart rate (FHR) decelerations?
a. Altered fetal cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Fetal hypoxemia
ANS: B
Variable FHR decelerations can occur at any time during the uterine contracting phase and
are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in
early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in
the FHR. Fetal hypoxemia initially results in tachycardia and then bradycardia if hypoxia
continues. NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
5. The nurse providing care for a high-risk laboring woman is alert for late fetal heart rate
(FHR) decelerations. Which clinical finding might be the cause for these late decelerations?
a. Altered cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Meconium fluid
ANS: C
Uteroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood
flow results in early FHR decelerations. Umbilical cord compression results in variable FHR
decelerations. Meconium-stained fluid may or may not produce changes in the FHR,
depending on the gestational age of the fetus and whether other causative factors associated
with fetal distress are present.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
, 6. Which fetal heart rate (FHR) finding is the most concerning to the nurse who is providing
care to a laboring client?
a. Accelerations with fetal movement
b. Early decelerations
c. Average FHR of 126 beats per minute
d. Late decelerations
ANS: D
Late decelerations are caused by uteroplacental insufficiency and are associated with fetal
hypoxemia. Late FHR decelerations are considered ominous if they are persistent and left
uncorrected. Accelerations with fetal movement are an indication of fetal well-being. Early
decelerations in the FHR are associated with head compression as the fetus descends into
the maternal pelvic outlet; they are not generally a concern during normal labor. An FHR
finding of 126 beats per minute is normal and not a concern.
PTS: 1 DIF: Cognitive Level: Analyze
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
7. The nurse who provides care to clients in labor must have a thorough understanding of the
physiologic processes of maternal hypotension. Which outcome might occur if the
interventions for maternal hypotension are inadequate?
a. Early fetal heart rate (FHR) decelerations
b. Fetal arrhythmias
c. Uteroplacental insufficiency
d. Spontaneous rupture of membranes
ANS: C NURSINGTB.COM
Low maternal blood pressure reduces placental blood flow during uterine contractions,
resulting in fetal hypoxemia. Maternal hypotension does not result in early FHR
decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes
is not a result of maternal hypotension.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
8. What are the legal responsibilities of the perinatal nurses?
a. Correctly interpreting fetal heartrate (FHR) patterns, initiating appropriate nursing
interventions, and documenting the outcomes
b. Greeting the client on arrival, assessing her status, and starting an IV line
c. Applying the external fetal monitor and notifying the health care provider
d. Ensuring that the woman is comfortable
ANS: A
MULTIPLE CHOICE
1. What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?
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’ response to fetal head compression; these are considered
benign, and interventions are not necessary. Variable decelerations are associated with
umbilical cord compression. Late decelerations are associated with uteroplacental
insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the
umbilical cord prolapses, which would result in variable or prolonged bradycardia.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
2. Which clinical finding or intervention might be considered the rationale for fetal tachycardia
to occur?
a. Maternal fever
b. Umbilical cord prolapseNURSINGTB.COM
c. Regional anesthesia
d. Magnesium sulfate administration
ANS: A
Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result
from maternal or fetal infection. Umbilical cord prolapse, regional anesthesia, and the
administration of magnesium sulfate will each more likely result in fetal bradycardia, not
tachycardia.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
3. 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.
What is the nurse’s first priority?
a. Change the woman’s position.
b. Notify the health care provider.
c. Assist with amnioinfusion
d. Insert a scalp electrode.
ANS: A
, Late FHR decelerations may be caused by maternal supine hypotension syndrome. These
decelerations are usually corrected when the woman turns onto 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, then the nurse should continue with subsequent
intrauterine resuscitation measures and notify the health 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 will reveal variable decelerations. Although
a fetal scalp electrode will provide accurate data for evaluating the well-being of the fetus, it
is not a nursing intervention that will alleviate late decelerations nor is it the nurse’s first
priority.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
4. What is the most likely cause for variable fetal heart rate (FHR) decelerations?
a. Altered fetal cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Fetal hypoxemia
ANS: B
Variable FHR decelerations can occur at any time during the uterine contracting phase and
are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in
early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in
the FHR. Fetal hypoxemia initially results in tachycardia and then bradycardia if hypoxia
continues. NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
5. The nurse providing care for a high-risk laboring woman is alert for late fetal heart rate
(FHR) decelerations. Which clinical finding might be the cause for these late decelerations?
a. Altered cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Meconium fluid
ANS: C
Uteroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood
flow results in early FHR decelerations. Umbilical cord compression results in variable FHR
decelerations. Meconium-stained fluid may or may not produce changes in the FHR,
depending on the gestational age of the fetus and whether other causative factors associated
with fetal distress are present.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity, Health Promotion and Maintenance
, 6. Which fetal heart rate (FHR) finding is the most concerning to the nurse who is providing
care to a laboring client?
a. Accelerations with fetal movement
b. Early decelerations
c. Average FHR of 126 beats per minute
d. Late decelerations
ANS: D
Late decelerations are caused by uteroplacental insufficiency and are associated with fetal
hypoxemia. Late FHR decelerations are considered ominous if they are persistent and left
uncorrected. Accelerations with fetal movement are an indication of fetal well-being. Early
decelerations in the FHR are associated with head compression as the fetus descends into
the maternal pelvic outlet; they are not generally a concern during normal labor. An FHR
finding of 126 beats per minute is normal and not a concern.
PTS: 1 DIF: Cognitive Level: Analyze
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
7. The nurse who provides care to clients in labor must have a thorough understanding of the
physiologic processes of maternal hypotension. Which outcome might occur if the
interventions for maternal hypotension are inadequate?
a. Early fetal heart rate (FHR) decelerations
b. Fetal arrhythmias
c. Uteroplacental insufficiency
d. Spontaneous rupture of membranes
ANS: C NURSINGTB.COM
Low maternal blood pressure reduces placental blood flow during uterine contractions,
resulting in fetal hypoxemia. Maternal hypotension does not result in early FHR
decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes
is not a result of maternal hypotension.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
8. What are the legal responsibilities of the perinatal nurses?
a. Correctly interpreting fetal heartrate (FHR) patterns, initiating appropriate nursing
interventions, and documenting the outcomes
b. Greeting the client on arrival, assessing her status, and starting an IV line
c. Applying the external fetal monitor and notifying the health care provider
d. Ensuring that the woman is comfortable
ANS: A
