Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig)

Chapter 20 Intrapartum Nursing Assessment

1. The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status?
2. "How did you decide to have your baby at this hospital?"
3. "Who will be your labor support person?"
4. "Have you chosen names for your baby yet?"
5. "What feeding method will you use for your baby?"

Page Ref: 456

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician?
2. Blood pressure 120/88
3. Father a carrier of sickle-cell trait
4. Dark red vaginal bleeding
5. History of domestic abuse

Page Ref: 458

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | A A C N Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | N L N Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is reviewing the F H R monitor for a client in labor. The rhythm strip yields the following result:

How should the nurse interpret this pattern?

1. Moderate variability
2. Minimal variability
3. Absent variability
4. Marked variability

Page Ref: 484

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Discuss fetal heart rates and patterns using National Institute of Child Health and Human Development (N I C H D) terminology.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. While caring for a client in labor, the nurse notes the following F H R pattern:

Which action should the nurse perform?

1. Continue to monitor the client
2. Fetal scalp stimulation
3. Palpate contraction strength
4. Discontinue oxytocin

Page Ref: 482

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Relationship-Centered Care: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 7 Discuss fetal heart rates and patterns using National Institute of Child Health and Human Development (N I C H D) terminology.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is caring for a client undergoing fetal heart rate monitoring, and the F H R is greater than 162 beats/min for 12 minutes. For what cause(s) should the nurse anticipate treatment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Maternal anxiety
2. Fetal asphyxia
3. Prematurity
4. Fetal anemia
5. Maternal hypotension

Page Ref: 482

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 6 Examine the differences between fetal tachycardia and fetal bradycardia.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus?
2. Infection
3. Umbilical cord compression
4. Vagus nerve stimulation
5. Hypoxemia

Page Ref: 482

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Examine the differences between fetal tachycardia and fetal bradycardia.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is caring for a client who has experienced premature rupture of membranes. For which maternal implication(s) should the nurse monitor?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Infection
2. Preterm labor
3. Dyspnea
4. Discomfort
5. E) Uterine distention

Page Ref: 459

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 2 Discuss the outer limits of normal progress of each of the phases and stages of labor.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is assessing the baseline fetal heart rate for a client in labor.

What action should the nurse take first?

1. Measure the fetal heart rate for 10 minutes
2. Round the heart rate to increments of 5 beats/minute
3. Exclude periods of marked variation
4. Calculate the mean (average) heart rate

Page Ref: 482

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 8 Explain the steps to be performed in the systematic evaluation of fetal heart rate tracings.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. While caring for a client in labor, the nurse notes the following persistent rhythm on the fetal heart rate monitor:

Which action should the nurse take first?

1. Notify the provider.
2. Prepare for expedient delivery.
3. Reposition the client.
4. Discontinue oxytocin therapy.

Page Ref: 483

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 8 Explain the steps to be performed in the systematic evaluation of fetal heart rate tracings.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention?
2. Woman at 7 c m, fetal heart tones auscultated every 90 minutes
3. Woman at 10 c m and pushing, external fetal monitor applied
4. Woman with meconium-stained fluid, internal fetal scalp electrode in use
5. Woman in preterm labor, external monitor in place

Page Ref: 469

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important?
2. "The monitor is necessary so we can see how your labor is progressing."
3. "The monitor will prevent complications from the meconium in your fluid."
4. "The monitor helps us to see how the baby is tolerating labor."
5. "The monitor can be removed, and oxygen given instead."

Page Ref: 478

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively: listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse has just palpated contractions and compares the consistency to that of the forehead in order to estimate the firmness of the fundus. What would the intensity of these contractions be identified as?
2. Mild
3. Moderate
4. Strong
5. Weak

Page Ref: 470

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. Before performing Leopold maneuvers, what would the nurse do?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Have the client empty her bladder.
2. Place the client in Trendelenburg position.
3. Have the client lie on her back with her feet on the bed and knees bent.
4. Turn the client to her left side.
5. This is not the optimal position for the client when performing Leopold maneuvers.

Page Ref: 473

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse?
2. The client is assisted into supine position, and the position of the fetus is assessed.
3. The upper portion of the uterus is palpated, then the middle section.
4. After determining where the back is located, the cervix is assessed.
5. Following voiding, the client's abdomen is palpated from top to bottom.

Page Ref: 473

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team. | A A C N Essentials Competencies: Ⅱ. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team. | N L N Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first?
2. Perform Leopold maneuvers to determine fetal position.
3. Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (U C).
4. Dry the maternal abdomen before using the Doppler.
5. The diaphragm should be cooled before using the Doppler.

Page Ref: 474

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. After several hours of labor, the electronic fetal monitor (E F M) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following?
2. Breech presentation
3. Uteroplacental insufficiency
4. Compression of the fetal head
5. Umbilical cord compression

Page Ref: 483

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse auscultates the F H R and determines a rate of 112 beats/min. Which action is appropriate?
2. Inform the maternal client that the rate is normal.
3. Reassess the F H R in 5 minutes because the rate is low.
4. Report the F H R to the doctor immediately.
5. Turn the maternal client on her side and administer oxygen.

Page Ref: 482

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. Upon assessing the F H R tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Early fetal hypoxia
2. Prolonged fetal stimulation
3. Fetal anemia
4. Fetal sleep cycle
5. Infection

Page Ref: 482

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. Persistent early decelerations are noted. What would the nurse's first action be?
2. Turn the mother on her left side and give oxygen.
3. Check for prolapsed cord.
4. Do nothing. This is a benign pattern.
5. Prepare for immediate forceps or cesarean delivery.

Page Ref: 487

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best?
2. Document the fetal heart rate.
3. Apply oxygen via mask at 10 liters.
4. Prepare for imminent delivery.
5. Assist the client into Fowler's position.

Page Ref: 487

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately?
2. Change the client's position in bed.
3. Notify the physician that birth is imminent.
4. Administer oxygen at 2 liters per minute.
5. Begin continuous fetal heart rate monitoring.

Page Ref: 463

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching?
2. "The most important part of fetal heart monitoring is the absence of variable decelerations."
3. "The most important part of fetal heart monitoring is the presence of variability."
4. "The most important part of fetal heart monitoring is the fetal heart rate baseline."
5. "The most important part of fetal heart monitoring is the depth of decelerations."

Page Ref: 484

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best?
2. Assist the client to change position.
3. Apply oxygen to the client at 2 liters per nasal cannula.
4. Notify the operating room of the need for a cesarean birth.
5. Determine the color of the leaking amniotic fluid.

Page Ref: 488

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 9 Evaluate abnormal findings on a fetal heart rate tracing.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. Fetal factors that possibly indicate electronic fetal monitoring include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Meconium passage
2. Multiple gestation
3. Preeclampsia
4. Grand multiparity
5. Decreased fetal movement

Page Ref: 480

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention?
2. Early decelerations with each contraction
3. Variable decelerations that recover to the baseline
4. Late decelerations with minimal variability
5. Accelerations

Page Ref: 488

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 10 Explain the interventions that are indicated when a nonreassuring fetal heart rate pattern is identified.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following?
2. Moderate variability
3. Early decelerations
4. Late decelerations
5. Accelerations

Page Ref: 488

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 10 Explain the interventions that are indicated when a nonreassuring fetal heart rate pattern is identified.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what?
2. Increase the mother's oxygen rate.
3. Turn the mother to the left lateral position.
4. Prepare the mother for a higher-risk delivery.
5. Increase the intravenous infusion rate.

Page Ref: 493

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip?
2. Late decelerations
3. Early decelerations
4. Accelerations
5. Fetal dysrhythmia

Page Ref: 493

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 11 Describe the steps used to perform fetal scalp stimulation.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse?
2. "I stimulated the top of the fetus's head to wake him up a little."
3. "I stimulated the top of the fetus's head to try to get his heart rate to accelerate."
4. "I stimulated the top of the fetus's head to calm the fetus down before birth."
5. "I stimulated the top of the fetus's head to find out whether he is in distress."

Page Ref: 493

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 11 Describe the steps used to perform fetal scalp stimulation.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. During an intrapartum vaginal examination the nurse palpates the following:

Based upon this information, which diagram best describes the fetal descent and station?

Page Ref: 472

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process.

Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The fetus of a laboring patient is in the following position:

What should the nurse expect when conducting the intrapartum vaginal examination?

Page Ref: 473

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 2 Discuss the outer limits of normal progress of each of the phases and stages of labor.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The nurse is performing Leopold maneuvers with a patient in the 3rd trimester of pregnancy. Which maneuver should the nurse perform first?

Page Ref: 475

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process.

Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. The fetus of a pregnant patient is in the right occiput anterior (R O A) position. Where should the nurse auscultate the fetal heart sounds?

1. A
2. B
3. C
4. D

Page Ref: 476

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

1. A laboring patient being monitored has the following rhythm strip:

How should the nurse interpret this finding?

1. Early decelerations
2. Periodic accelerations
3. Episodic accelerations
4. Variable decelerations with overshoot

Page Ref: 486

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 9 Evaluate abnormal findings on a fetal heart rate tracing.

M N L L O: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.