Chapter 15: Fetal Assessment during Labor NCLEX(with
Accurate answers)
When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate
from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this
decrease in baseline to:
A. Maternal hyperthyroidism.
B. Initiation of epidural anesthesia that resulted in maternal hypotension.
C. Maternal infection accompanied by fever.
D. Alteration in maternal position from semirecumbent to lateral. correct answers B
(Initiation of epidural anesthesia that resulted in maternal hypotension.
Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described
and results from the hypoxia that would occur when uteroplacental perfusion is reduced by
maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated
before and during induction of the anesthesia to maintain an adequate cardiac output and blood
pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position
enhances placental perfusion and should result in a reassuring FHR pattern.)
On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart
rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse
should:
A. Describe the finding in the nurse's notes.
B. Reposition the woman onto her side.
C. Call the physician for instructions.
D. Administer oxygen at 8 to 10 L/min with a tight face mask. correct answers A
(Describe the finding in the nurse's notes.
An early deceleration pattern from head compression is described. No action other than
documentation of the finding is required since this is an expected reaction to compression of the
fetal head as it passes through the cervix. These actions would be implemented when non-
reassuring or ominous changes are noted. These actions would be implemented when non-
reassuring or ominous changes are noted. These actions would be implemented when non-
reassuring or ominous changes are noted.)
Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?
A. FHR does not change as a result of fetal activity.
B. Average baseline rate ranges between 100 and 140 beats/min.
C. Mild late deceleration patterns occur with some contractions.
D. Variability averages between 6 to 10 beats/min. correct answers D
,(Variability averages between 6 to 10 beats/min.
FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min.
Late deceleration patterns are never reassuring, although early and mild variable decelerations
are expected, reassuring findings. Variability indicates a well-oxygenated fetus with a
functioning autonomic nervous system.)
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor
is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital
signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and
occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to:
A. Change the woman's position.
B. Stop the Pitocin.
C. Elevate the woman's legs.
D. Administer oxygen via a tight mask at 8 to 10 L/min. correct answers B
(Stop the Pitocin.
The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration
patterns noted are most likely related to alteration in uteroplacental perfusion associated with the
strong contractions described. The immediate action would be to stop the Pitocin infusion since
Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be
appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.)
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you
see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the
mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has
not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing
measures should you take?
A. Notify nursery nurse of imminent delivery.
B. Insert a Foley catheter.
C. Start oxytocin (Pitocin).
D. Notify the primary health care provider immediately (HCP). correct answers D
(Notify the primary health care provider immediately (HCP).
This is not the most important nursing measure at this time. The patient needs to be evaluated by
the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to
continue in an abnormal or non-reassuring pattern, a cesarean section may be warranted. This
would require the insertion of a Foley catheter; however, the physician must make that
determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration,
the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is
, infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider
should be notified immediately.)
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:
A. The examiner's hand should be placed over the fundus before, during, and after contractions.
B. The frequency and duration of contractions are measured in seconds for consistency.
C. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together.
D. The resting tone between contractions is described as either placid or turbulent. correct
answers A
(The examiner's hand should be placed over the fundus before, during, and after contractions.
The assessment is done by palpation; duration, frequency, intensity, and resting tone must be
assessed. The duration of contractions is measured in seconds; the frequency is measured in
minutes. The intensity of contractions usually is described as mild, moderate, or strong. The
resting tone usually is characterized as soft or relaxed.)
A nurse caring for a woman in labor understands that increased variability of the fetal heart rate
might be caused by:
A. Narcotics.
B. Barbiturates.
C. Methamphetamines.
D. Tranquilizers. correct answers C
(Methamphetamines.
Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates
may also result in a significant decrease in variability as these are known to cross the placental
barrier. The use of illicit drugs, such as cocaine or methamphetamines, might cause increased
variability. Tranquilizer use is a possible cause of decreased variability in the fetal heart rate.)
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:
A. Change in position.
B. Oxytocin administration.
C. Regional anesthesia.
D. Intravenous analgesic. correct answers A
(Change in position.
Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus
on the ascending vena cava when the woman is in a supine position. This reduces venous return
to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The
nurse can encourage the woman to change positions and avoid the supine position. Oxytocin
Accurate answers)
When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate
from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this
decrease in baseline to:
A. Maternal hyperthyroidism.
B. Initiation of epidural anesthesia that resulted in maternal hypotension.
C. Maternal infection accompanied by fever.
D. Alteration in maternal position from semirecumbent to lateral. correct answers B
(Initiation of epidural anesthesia that resulted in maternal hypotension.
Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described
and results from the hypoxia that would occur when uteroplacental perfusion is reduced by
maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated
before and during induction of the anesthesia to maintain an adequate cardiac output and blood
pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position
enhances placental perfusion and should result in a reassuring FHR pattern.)
On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart
rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse
should:
A. Describe the finding in the nurse's notes.
B. Reposition the woman onto her side.
C. Call the physician for instructions.
D. Administer oxygen at 8 to 10 L/min with a tight face mask. correct answers A
(Describe the finding in the nurse's notes.
An early deceleration pattern from head compression is described. No action other than
documentation of the finding is required since this is an expected reaction to compression of the
fetal head as it passes through the cervix. These actions would be implemented when non-
reassuring or ominous changes are noted. These actions would be implemented when non-
reassuring or ominous changes are noted. These actions would be implemented when non-
reassuring or ominous changes are noted.)
Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?
A. FHR does not change as a result of fetal activity.
B. Average baseline rate ranges between 100 and 140 beats/min.
C. Mild late deceleration patterns occur with some contractions.
D. Variability averages between 6 to 10 beats/min. correct answers D
,(Variability averages between 6 to 10 beats/min.
FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min.
Late deceleration patterns are never reassuring, although early and mild variable decelerations
are expected, reassuring findings. Variability indicates a well-oxygenated fetus with a
functioning autonomic nervous system.)
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor
is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital
signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and
occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to:
A. Change the woman's position.
B. Stop the Pitocin.
C. Elevate the woman's legs.
D. Administer oxygen via a tight mask at 8 to 10 L/min. correct answers B
(Stop the Pitocin.
The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration
patterns noted are most likely related to alteration in uteroplacental perfusion associated with the
strong contractions described. The immediate action would be to stop the Pitocin infusion since
Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be
appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.)
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you
see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the
mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has
not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing
measures should you take?
A. Notify nursery nurse of imminent delivery.
B. Insert a Foley catheter.
C. Start oxytocin (Pitocin).
D. Notify the primary health care provider immediately (HCP). correct answers D
(Notify the primary health care provider immediately (HCP).
This is not the most important nursing measure at this time. The patient needs to be evaluated by
the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to
continue in an abnormal or non-reassuring pattern, a cesarean section may be warranted. This
would require the insertion of a Foley catheter; however, the physician must make that
determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration,
the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is
, infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider
should be notified immediately.)
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:
A. The examiner's hand should be placed over the fundus before, during, and after contractions.
B. The frequency and duration of contractions are measured in seconds for consistency.
C. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together.
D. The resting tone between contractions is described as either placid or turbulent. correct
answers A
(The examiner's hand should be placed over the fundus before, during, and after contractions.
The assessment is done by palpation; duration, frequency, intensity, and resting tone must be
assessed. The duration of contractions is measured in seconds; the frequency is measured in
minutes. The intensity of contractions usually is described as mild, moderate, or strong. The
resting tone usually is characterized as soft or relaxed.)
A nurse caring for a woman in labor understands that increased variability of the fetal heart rate
might be caused by:
A. Narcotics.
B. Barbiturates.
C. Methamphetamines.
D. Tranquilizers. correct answers C
(Methamphetamines.
Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates
may also result in a significant decrease in variability as these are known to cross the placental
barrier. The use of illicit drugs, such as cocaine or methamphetamines, might cause increased
variability. Tranquilizer use is a possible cause of decreased variability in the fetal heart rate.)
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:
A. Change in position.
B. Oxytocin administration.
C. Regional anesthesia.
D. Intravenous analgesic. correct answers A
(Change in position.
Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus
on the ascending vena cava when the woman is in a supine position. This reduces venous return
to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The
nurse can encourage the woman to change positions and avoid the supine position. Oxytocin
