EAQ NCLEX EXAM QUESTIONS WITH
COMPLETE SOLUTIONS
Which of these conditions may cause the fetal heart rate to be lower
| | | | | | | | | | | | |
during labor? (Choose all that apply.)
| | | | |
A. Stimulation of the sympathetic nervous system
| | | | | | |
B. Stimulation of the baroreceptors, which in turn stimulates the vagus
| | | | | | | | | | |
nerve |
C. Prolonged hypoxia, hypercapnia, and acidosis
| | | | | |
D. Stimulation of the parasympathetic nervous system - CORRECT
| | | | | | | | |
ANSWER✔✔-B, C, D | |
Stimulation of the baroreceptors and the parasympathetic nervous
| | | | | | | |
system will lower the heart rate. Initial decreased oxygen content and
| | | | | | | | | | |
increased carbon dioxide content will trigger an increase in the heart
| | | | | | | | | | |
rate. However, if this condition continues, the heart rate will lower.
| | | | | | | | | |
The nurse is monitoring the fetal heart rate periodically with Doppler
| | | | | | | | | | |
auscultation. At the end of a contraction, the fetal heart rate is 100 and
| | | | | | | | | | | | | |
gradually increases to 140 within 30 seconds. The nurse would need to
| | | | | | | | | | | |
assess the rate further, because this is an indication of ______________.
| | | | | | | | | |
- CORRECT ANSWER✔✔-Late deceleration
| | | |
,A late deceleration shows a pattern of fetal heart decelerations that
| | | | | | | | | | |
begin late in the contraction phase and goes back to baseline after the
| | | | | | | | | | | | |
contraction has ended. | |
A woman is admitted to the birthing unit in labor. Upon assessment, it is
| | | | | | | | | | | | |
noted that she is 3 cm dilated, 80% effaced with intact membranes. The
| | | | | | | | | | | | |
nurse understands that her fetal monitoring will be done by
| | | | | | | | | | |
___________. - CORRECT ANSWER✔✔-External electrodes | | | |
To use internal electrodes, the woman mush be 2 cm dilated and have
| | | | | | | | | | | | |
ruptured membranes. Her membranes are intact. Therefore, external
| | | | | | | |
electrode monitoring is the choice of her.
| | | | | |
The nurse sees a pattern on the fetal monitor that looks similar to early
| | | | | | | | | | | | | |
decelerations, but the deceleration begins near the acme of the | | | | | | | | | |
contraction and continues well beyond the end of the contraction.
| | | | | | | | | |
Which nursing action indicates the proper evaluation of this situation?
| | | | | | | | |
A. Continue to monitor these early decelerations, which occur as the
| | | | | | | | | | |
fetal head is compressed during a contraction.
| | | | | | |
B. This deceleration pattern is associated with uteroplacental
| | | | | | | |
insufficiency, so the nurse acts quickly to improve placental blood flow
| | | | | | | | | | |
and fetal oxygen supply.
| | | |
C. This pattern reflects variable decelerations. No interventions are
| | | | | | | | |
necessary at this time. | | | |
,D. Document this reassuring fetal heart rate pattern but decrease the
| | | | | | | | | | |
rate of the intravenous fluid. - CORRECT ANSWER✔✔-B
| | | | | | |
A. An early deceleration would end when the contraction phase is over.
| | | | | | | | | | | |
This pattern continues beyond the end of the contraction.
| | | | | | | |
B. This is a description of a late deceleration. Oxygen should be given via
| | | | | | | | | | | | |
|snug facemask. The nurse should position the woman on her side to
| | | | | | | | | | | |
increase placental blood flow. | | | |
C. Variable decelerations drop suddenly and return to baseline
| | | | | | | | |
suddenly. They are caused by cord compression. A vaginal examination
| | | | | | | | | |
should be performed to identify this potential emergency.
| | | | | | |
D. This pattern is nonreassuring. The intravenous fluid should be
| | | | | | | | | |
increased to increase the woman's blood volume.
| | | | | |
Proper placement of the tocotransducer for electronic fetal monitoring
| | | | | | | | |
is
A. Over the uterine fundus
| | | | |
B. On the fetal scalp
| | | | |
C. Inside the uterus
| | | |
D. Over the mother's lower abdomen - CORRECT ANSWER✔✔-A
| | | | | | | |
A. The tocotransducer monitors uterine activity and should be placed
| | | | | | | | | |
over the fundus where the most intensive uterine contractions occur.
| | | | | | | | |
B. This is the placement for the internal scalp electrode.
| | | | | | | | |
C. This is the placement for the intrauterine pressure catheter.
| | | | | | | | |
, D. The tocotransducer does not detect contractions if placed on the
| | | | | | | | | | |
lower abdomen |
After monitoring the fetal heart rate for 10 minutes, the nurse notices
| | | | | | | | | | | |
the rate is staying at 175 bpm. The nurse is correct in classifying this
| | | | | | | | | | | | | |
baseline rate as | |
A. Normal
| |
B. Bradycardia
| |
C. Tachycardia
| |
D. Acceleration - CORRECT ANSWER✔✔-C
| | | |
A. A normal rate averages between 110 and 160 bpm.
| | | | | | | | |
B. Bradycardia is a rate less than 110 bpm for at least 10 minutes.
| | | | | | | | | | | | |
C. Tachycardia is a heart rate greater than 160 bpm, persisting for at
| | | | | | | | | | | | |
least 10 minutes.
| |
D. Acceleration is an increase in the heart rate that lasts for a short
| | | | | | | | | | | | | |
period of time before returning to baseline
| | | | | |
What can be determined only by electronic fetal monitoring?
| | | | | | | |
A. Variability
| |
B. Tachycardia
| |
COMPLETE SOLUTIONS
Which of these conditions may cause the fetal heart rate to be lower
| | | | | | | | | | | | |
during labor? (Choose all that apply.)
| | | | |
A. Stimulation of the sympathetic nervous system
| | | | | | |
B. Stimulation of the baroreceptors, which in turn stimulates the vagus
| | | | | | | | | | |
nerve |
C. Prolonged hypoxia, hypercapnia, and acidosis
| | | | | |
D. Stimulation of the parasympathetic nervous system - CORRECT
| | | | | | | | |
ANSWER✔✔-B, C, D | |
Stimulation of the baroreceptors and the parasympathetic nervous
| | | | | | | |
system will lower the heart rate. Initial decreased oxygen content and
| | | | | | | | | | |
increased carbon dioxide content will trigger an increase in the heart
| | | | | | | | | | |
rate. However, if this condition continues, the heart rate will lower.
| | | | | | | | | |
The nurse is monitoring the fetal heart rate periodically with Doppler
| | | | | | | | | | |
auscultation. At the end of a contraction, the fetal heart rate is 100 and
| | | | | | | | | | | | | |
gradually increases to 140 within 30 seconds. The nurse would need to
| | | | | | | | | | | |
assess the rate further, because this is an indication of ______________.
| | | | | | | | | |
- CORRECT ANSWER✔✔-Late deceleration
| | | |
,A late deceleration shows a pattern of fetal heart decelerations that
| | | | | | | | | | |
begin late in the contraction phase and goes back to baseline after the
| | | | | | | | | | | | |
contraction has ended. | |
A woman is admitted to the birthing unit in labor. Upon assessment, it is
| | | | | | | | | | | | |
noted that she is 3 cm dilated, 80% effaced with intact membranes. The
| | | | | | | | | | | | |
nurse understands that her fetal monitoring will be done by
| | | | | | | | | | |
___________. - CORRECT ANSWER✔✔-External electrodes | | | |
To use internal electrodes, the woman mush be 2 cm dilated and have
| | | | | | | | | | | | |
ruptured membranes. Her membranes are intact. Therefore, external
| | | | | | | |
electrode monitoring is the choice of her.
| | | | | |
The nurse sees a pattern on the fetal monitor that looks similar to early
| | | | | | | | | | | | | |
decelerations, but the deceleration begins near the acme of the | | | | | | | | | |
contraction and continues well beyond the end of the contraction.
| | | | | | | | | |
Which nursing action indicates the proper evaluation of this situation?
| | | | | | | | |
A. Continue to monitor these early decelerations, which occur as the
| | | | | | | | | | |
fetal head is compressed during a contraction.
| | | | | | |
B. This deceleration pattern is associated with uteroplacental
| | | | | | | |
insufficiency, so the nurse acts quickly to improve placental blood flow
| | | | | | | | | | |
and fetal oxygen supply.
| | | |
C. This pattern reflects variable decelerations. No interventions are
| | | | | | | | |
necessary at this time. | | | |
,D. Document this reassuring fetal heart rate pattern but decrease the
| | | | | | | | | | |
rate of the intravenous fluid. - CORRECT ANSWER✔✔-B
| | | | | | |
A. An early deceleration would end when the contraction phase is over.
| | | | | | | | | | | |
This pattern continues beyond the end of the contraction.
| | | | | | | |
B. This is a description of a late deceleration. Oxygen should be given via
| | | | | | | | | | | | |
|snug facemask. The nurse should position the woman on her side to
| | | | | | | | | | | |
increase placental blood flow. | | | |
C. Variable decelerations drop suddenly and return to baseline
| | | | | | | | |
suddenly. They are caused by cord compression. A vaginal examination
| | | | | | | | | |
should be performed to identify this potential emergency.
| | | | | | |
D. This pattern is nonreassuring. The intravenous fluid should be
| | | | | | | | | |
increased to increase the woman's blood volume.
| | | | | |
Proper placement of the tocotransducer for electronic fetal monitoring
| | | | | | | | |
is
A. Over the uterine fundus
| | | | |
B. On the fetal scalp
| | | | |
C. Inside the uterus
| | | |
D. Over the mother's lower abdomen - CORRECT ANSWER✔✔-A
| | | | | | | |
A. The tocotransducer monitors uterine activity and should be placed
| | | | | | | | | |
over the fundus where the most intensive uterine contractions occur.
| | | | | | | | |
B. This is the placement for the internal scalp electrode.
| | | | | | | | |
C. This is the placement for the intrauterine pressure catheter.
| | | | | | | | |
, D. The tocotransducer does not detect contractions if placed on the
| | | | | | | | | | |
lower abdomen |
After monitoring the fetal heart rate for 10 minutes, the nurse notices
| | | | | | | | | | | |
the rate is staying at 175 bpm. The nurse is correct in classifying this
| | | | | | | | | | | | | |
baseline rate as | |
A. Normal
| |
B. Bradycardia
| |
C. Tachycardia
| |
D. Acceleration - CORRECT ANSWER✔✔-C
| | | |
A. A normal rate averages between 110 and 160 bpm.
| | | | | | | | |
B. Bradycardia is a rate less than 110 bpm for at least 10 minutes.
| | | | | | | | | | | | |
C. Tachycardia is a heart rate greater than 160 bpm, persisting for at
| | | | | | | | | | | | |
least 10 minutes.
| |
D. Acceleration is an increase in the heart rate that lasts for a short
| | | | | | | | | | | | | |
period of time before returning to baseline
| | | | | |
What can be determined only by electronic fetal monitoring?
| | | | | | | |
A. Variability
| |
B. Tachycardia
| |
