NUR 2513 MATERNAL CHILD NURSING EXAM 2 |
QUESTIONS AND ANSWERS | 2026 UPDATE | WITH
COMPLETE SOLUTIONS.
SECTION 1: FETAL MONITORING & INTRAPARTUM ASSESSMENT
1. The nurse notes late decelerations on the fetal monitor that are recurrent and
have been present for the past 20 minutes. Which nursing intervention should
the nurse perform FIRST?
A) Notify the healthcare provider
B) Reposition the client to the left side
C) Increase the IV fluid rate
D) Administer oxygen via face mask
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority
nursing intervention is to reposition the client to the left side to improve placental
perfusion by relieving pressure on the vena cava. Other interventions include
increasing IV fluids, administering oxygen, and notifying the provider, but
repositioning is the immediate first step .
2. A fetal heart rate tracing shows minimal variability and recurrent late
decelerations. What is the most appropriate nursing action?
A) Continue to monitor and document
B) Administer oral fluids
C) Prepare for immediate delivery
D) Notify the healthcare provider and implement intrauterine resuscitation
measures
,Correct Answer: D
Rationale: Minimal variability (2-5 bpm) combined with recurrent late
decelerations is a concerning, non-reassuring pattern that may indicate fetal
acidosis and hypoxia. This is classified as a Category III tracing requiring
immediate intervention. The nurse should notify the healthcare provider
immediately and implement intrauterine resuscitation measures (reposition,
oxygen, IV fluids). The provider will determine if immediate delivery is necessary .
3. The nurse notes a fetal heart rate of 95 bpm on a laboring client. What is the
correct interpretation and action?
A) Normal FHR; continue to monitor
B) Tachycardia; notify the provider
C) Bradycardia; implement intrauterine resuscitation
D) Normal FHR; increase IV fluids
Correct Answer: C
Rationale: Fetal bradycardia is defined as an FHR of less than 110 bpm that
persists for 10 minutes or longer. Bradycardia is a non-reassuring finding that
requires intervention. The nurse should implement intrauterine resuscitation and
notify the healthcare provider .
4. What is the significance of a sinusoidal pattern on the fetal monitor?
A) It is a benign finding associated with fetal sleep
B) It is a reassuring finding indicating fetal well-being
C) It is a Category III tracing requiring immediate intervention
D) It indicates fetal head compression
Correct Answer: C
Rationale: A sinusoidal pattern is a smooth, sine-wave-like undulating pattern with
absent variability. It is a Category III tracing associated with severe fetal anemia,
,fetal distress, and often Rh isoimmunization. It requires immediate intervention
and notification of the healthcare provider .
5. What does variability in the fetal heart rate indicate about the fetus?
A) The fetus is sleeping
B) The fetus is in distress
C) The fetus has an intact autonomic nervous system
D) The fetus is experiencing cord compression
Correct Answer: C
Rationale: Fetal heart rate variability reflects the interaction between the
sympathetic and parasympathetic nervous systems. Moderate variability (6-25
bpm) is a reassuring sign indicating the fetus has an intact, well-oxygenated
autonomic nervous system .
6. Accelerations in the fetal heart rate are defined as:
A) Transient increases in FHR above baseline lasting at least 15 seconds and
peaking at 15 bpm above baseline
B) Transient decreases in FHR below baseline
C) An FHR below 110 bpm
D) An FHR above 160 bpm
Correct Answer: A
Rationale: Accelerations are transient increases in FHR above baseline that last at
least 15 seconds and peak at 15 bpm above baseline for fetuses ≥32 weeks
gestation. Accelerations are a reassuring sign of fetal well-being and indicate an
intact autonomic nervous system .
7. A patient in active labor has a fetal heart rate tracing showing late
decelerations. What is the nurse's priority action?
, A) Decrease IV fluids
B) Reposition the patient to her left side
C) Prepare for immediate cesarean section
D) Administer oxytocin to augment labor
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. Priority nursing
interventions include repositioning the patient to the left lateral side, increasing IV
fluids, administering oxygen via face mask, and notifying the healthcare provider.
The goal is to improve placental perfusion and fetal oxygenation .
8. Variable decelerations in the fetal heart rate are most consistent with:
A) Maternal bradycardia
B) Umbilical cord compression
C) Uteroplacental insufficiency
D) Fetal head compression
Correct Answer: B
Rationale: Variable decelerations are caused by umbilical cord compression. They
are characterized by a rapid decrease and return to baseline FHR and vary in
shape and timing with contractions .
9. Late decelerations in the fetal heart rate are indicative of:
A) Head compression
B) Cord compression
C) Uteroplacental insufficiency
D) Maternal hypotension
Correct Answer: C
Rationale: Late decelerations are caused by uteroplacental insufficiency, resulting
in decreased oxygen delivery to the fetus. They begin after the peak of the
QUESTIONS AND ANSWERS | 2026 UPDATE | WITH
COMPLETE SOLUTIONS.
SECTION 1: FETAL MONITORING & INTRAPARTUM ASSESSMENT
1. The nurse notes late decelerations on the fetal monitor that are recurrent and
have been present for the past 20 minutes. Which nursing intervention should
the nurse perform FIRST?
A) Notify the healthcare provider
B) Reposition the client to the left side
C) Increase the IV fluid rate
D) Administer oxygen via face mask
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority
nursing intervention is to reposition the client to the left side to improve placental
perfusion by relieving pressure on the vena cava. Other interventions include
increasing IV fluids, administering oxygen, and notifying the provider, but
repositioning is the immediate first step .
2. A fetal heart rate tracing shows minimal variability and recurrent late
decelerations. What is the most appropriate nursing action?
A) Continue to monitor and document
B) Administer oral fluids
C) Prepare for immediate delivery
D) Notify the healthcare provider and implement intrauterine resuscitation
measures
,Correct Answer: D
Rationale: Minimal variability (2-5 bpm) combined with recurrent late
decelerations is a concerning, non-reassuring pattern that may indicate fetal
acidosis and hypoxia. This is classified as a Category III tracing requiring
immediate intervention. The nurse should notify the healthcare provider
immediately and implement intrauterine resuscitation measures (reposition,
oxygen, IV fluids). The provider will determine if immediate delivery is necessary .
3. The nurse notes a fetal heart rate of 95 bpm on a laboring client. What is the
correct interpretation and action?
A) Normal FHR; continue to monitor
B) Tachycardia; notify the provider
C) Bradycardia; implement intrauterine resuscitation
D) Normal FHR; increase IV fluids
Correct Answer: C
Rationale: Fetal bradycardia is defined as an FHR of less than 110 bpm that
persists for 10 minutes or longer. Bradycardia is a non-reassuring finding that
requires intervention. The nurse should implement intrauterine resuscitation and
notify the healthcare provider .
4. What is the significance of a sinusoidal pattern on the fetal monitor?
A) It is a benign finding associated with fetal sleep
B) It is a reassuring finding indicating fetal well-being
C) It is a Category III tracing requiring immediate intervention
D) It indicates fetal head compression
Correct Answer: C
Rationale: A sinusoidal pattern is a smooth, sine-wave-like undulating pattern with
absent variability. It is a Category III tracing associated with severe fetal anemia,
,fetal distress, and often Rh isoimmunization. It requires immediate intervention
and notification of the healthcare provider .
5. What does variability in the fetal heart rate indicate about the fetus?
A) The fetus is sleeping
B) The fetus is in distress
C) The fetus has an intact autonomic nervous system
D) The fetus is experiencing cord compression
Correct Answer: C
Rationale: Fetal heart rate variability reflects the interaction between the
sympathetic and parasympathetic nervous systems. Moderate variability (6-25
bpm) is a reassuring sign indicating the fetus has an intact, well-oxygenated
autonomic nervous system .
6. Accelerations in the fetal heart rate are defined as:
A) Transient increases in FHR above baseline lasting at least 15 seconds and
peaking at 15 bpm above baseline
B) Transient decreases in FHR below baseline
C) An FHR below 110 bpm
D) An FHR above 160 bpm
Correct Answer: A
Rationale: Accelerations are transient increases in FHR above baseline that last at
least 15 seconds and peak at 15 bpm above baseline for fetuses ≥32 weeks
gestation. Accelerations are a reassuring sign of fetal well-being and indicate an
intact autonomic nervous system .
7. A patient in active labor has a fetal heart rate tracing showing late
decelerations. What is the nurse's priority action?
, A) Decrease IV fluids
B) Reposition the patient to her left side
C) Prepare for immediate cesarean section
D) Administer oxytocin to augment labor
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. Priority nursing
interventions include repositioning the patient to the left lateral side, increasing IV
fluids, administering oxygen via face mask, and notifying the healthcare provider.
The goal is to improve placental perfusion and fetal oxygenation .
8. Variable decelerations in the fetal heart rate are most consistent with:
A) Maternal bradycardia
B) Umbilical cord compression
C) Uteroplacental insufficiency
D) Fetal head compression
Correct Answer: B
Rationale: Variable decelerations are caused by umbilical cord compression. They
are characterized by a rapid decrease and return to baseline FHR and vary in
shape and timing with contractions .
9. Late decelerations in the fetal heart rate are indicative of:
A) Head compression
B) Cord compression
C) Uteroplacental insufficiency
D) Maternal hypotension
Correct Answer: C
Rationale: Late decelerations are caused by uteroplacental insufficiency, resulting
in decreased oxygen delivery to the fetus. They begin after the peak of the
