Maternity Nursing: Intrapartum
NCLEX Practice Questions #7 | 55
Questions
1. 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
Incorrect
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
Incorrect
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.
Incorrect
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.
Incorrect
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 (such as
movement) or by uterine contractions causes acceleration of the
FHR.
5. 5. Question
A nurse is admitting a pregnant client to the labor room and attaches
an external electronic fetal monitor to the client’s abdomen. After the
attachment of the monitor, the initial nursing assessment is which of
the following?
A. Identifying the types of accelerations
B. Assessing the baseline fetal heart rate
C. Determining the frequency of the contractions
NCLEX Practice Questions #7 | 55
Questions
1. 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
Incorrect
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
Incorrect
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.
Incorrect
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.
Incorrect
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 (such as
movement) or by uterine contractions causes acceleration of the
FHR.
5. 5. Question
A nurse is admitting a pregnant client to the labor room and attaches
an external electronic fetal monitor to the client’s abdomen. After the
attachment of the monitor, the initial nursing assessment is which of
the following?
A. Identifying the types of accelerations
B. Assessing the baseline fetal heart rate
C. Determining the frequency of the contractions
