1
Hatfield Introductory Maternity and
Pediatric Nursing 4th Edition Test
Bank.
Domain 1: Antepartum, Intrapartum & Postpartum Nursing (25 Questions)
1. The nurse is monitoring a laboring client and notes the presence of late fetal heart rate
decelerations on the external monitor strip. Which of the following is the priority nursing
intervention?
A. Increase the IV fluid rate to 150 mL/hr.
B. Administer a prescribed tocolytic medication.
C. Turn the mother to her left side, discontinue oxytocin, and apply oxygen via non-rebreather
mask.
D. Perform a vaginal examination to check for cervical dilation.
Answer: C [CORRECT]
Rationale: Late decelerations indicate uteroplacental insufficiency. The immediate priority is
to maximize oxygenation to the fetus by improving maternal blood flow (left lateral position
to relieve aortocaval compression), reducing uterine activity (stopping oxytocin), and
increasing maternal oxygen saturation (non-rebreather mask).
2. The nurse is caring for a client in active labor who is receiving oxytocin. The fetal heart rate
tracing shows recurrent late decelerations with decreasing variability. What is the nurse's first
action?
A. Check the maternal blood pressure.
B. Turn the client to the left side and stop the oxytocin infusion.
, 2
C. Call the anesthesiologist for an emergency cesarean section.
D. Document the finding and continue to monitor.
Answer: B [CORRECT]
Rationale: Recurrent late decelerations with decreased variability are signs of possible fetal
hypoxia. The first action is to implement interventions to improve placental perfusion, which
includes repositioning the mother to the left lateral side and immediately stopping the
oxytocin infusion to reduce uterine contractions.
3. A client in labor has late fetal heart rate decelerations. After positioning the client on her
left side and administering oxygen, the nurse should perform which of the following next?
A. Palpate the uterus for contractions.
B. Increase the oxytocin infusion rate.
C. Insert an internal fetal scalp electrode.
D. Perform a vaginal examination to rule out a prolapsed cord.
Answer: A [CORRECT]
Rationale: While immediate interventions (position change, oxygen, stopping oxytocin) are
taken, the nurse must simultaneously assess the uterus for contraction frequency and
intensity (hyperstimulation) which may be compromising placental blood flow. Increasing
oxytocin is contraindicated. Internal monitoring is not the immediate priority over stabilizing
the fetus.
4. Which of the following nursing actions is appropriate when late decelerations are noted on
the fetal monitor? (Select all that apply.)
A. Turn the mother to the left lateral position.
, 3
B. Administer oxygen via a non-rebreather mask at 8 to 10 L/min.
C. Discontinue the oxytocin infusion if running.
D. Encourage the mother to push with contractions.
E. Prepare for an immediate amniotomy.
Answer: A, B, C [CORRECT]
Rationale: Late decelerations require interventions to improve uteroplacental perfusion:
turning the mother to the left side relieves pressure on the vena cava, oxygen administration
increases maternal oxygen saturation, and discontinuing oxytocin reduces uterine activity that
may be compromising blood flow. Pushing or rupturing membranes would increase stress on
the fetus.
5. The nurse is caring for a laboring client with epidural anesthesia. The fetal heart rate shows
late decelerations. The nurse recognizes that the primary physiological cause of these
decelerations is:
A. Fetal head compression.
B. Umbilical cord compression.
C. Uteroplacental insufficiency.
D. Fetal hypoxia due to maternal fever.
Answer: C [CORRECT]
Rationale: Late decelerations are caused by uteroplacental insufficiency, where the placenta is
not exchanging oxygen and carbon dioxide efficiently enough to meet fetal demands during
contractions. This often occurs due to maternal hypotension (a side effect of epidural
anesthesia), which reduces blood flow to the placenta.
, 4
6. The nurse assesses a client 1 hour after a vaginal delivery and finds the fundus to be boggy,
soft, and displaced to the right of the umbilicus. What is the priority nursing intervention?
A. Document the finding and reassess in 30 minutes.
B. Encourage the client to ambulate to the bathroom.
C. Massage the uterine fundus until it is firm and expel any clots.
D. Administer a prescribed analgesic for pain relief.
Answer: C [CORRECT]
Rationale: A boggy (soft) uterus displaced to the right usually indicates a full bladder
preventing the uterus from contracting, or retained placental fragments/clots. The immediate
intervention is fundal massage to stimulate uterine contraction (myometrium firmness) and
expel any pooled blood to prevent postpartum hemorrhage. The bladder should be emptied
afterward.
7. A postpartum client has a fundus that is boggy and 2 fingerbreadths above the umbilicus.
Which of the following actions should the nurse take? (Select all that apply.)
A. Perform firm uterine massage.
B. Assess for bladder distention.
C. Administer methylergonovine (Methergine) if prescribed and blood pressure is stable.
D. Encourage oral fluid intake.
E. Place the client in the Trendelenburg position.
Answer: A, B, C [CORRECT]
Rationale: A boggy uterus indicates atony and risk of hemorrhage. Interventions include
uterine massage to stimulate contraction, assessing for a distended bladder (which prevents
contraction), and administering uterotonic agents like Methergine if ordered. While fluids are
Hatfield Introductory Maternity and
Pediatric Nursing 4th Edition Test
Bank.
Domain 1: Antepartum, Intrapartum & Postpartum Nursing (25 Questions)
1. The nurse is monitoring a laboring client and notes the presence of late fetal heart rate
decelerations on the external monitor strip. Which of the following is the priority nursing
intervention?
A. Increase the IV fluid rate to 150 mL/hr.
B. Administer a prescribed tocolytic medication.
C. Turn the mother to her left side, discontinue oxytocin, and apply oxygen via non-rebreather
mask.
D. Perform a vaginal examination to check for cervical dilation.
Answer: C [CORRECT]
Rationale: Late decelerations indicate uteroplacental insufficiency. The immediate priority is
to maximize oxygenation to the fetus by improving maternal blood flow (left lateral position
to relieve aortocaval compression), reducing uterine activity (stopping oxytocin), and
increasing maternal oxygen saturation (non-rebreather mask).
2. The nurse is caring for a client in active labor who is receiving oxytocin. The fetal heart rate
tracing shows recurrent late decelerations with decreasing variability. What is the nurse's first
action?
A. Check the maternal blood pressure.
B. Turn the client to the left side and stop the oxytocin infusion.
, 2
C. Call the anesthesiologist for an emergency cesarean section.
D. Document the finding and continue to monitor.
Answer: B [CORRECT]
Rationale: Recurrent late decelerations with decreased variability are signs of possible fetal
hypoxia. The first action is to implement interventions to improve placental perfusion, which
includes repositioning the mother to the left lateral side and immediately stopping the
oxytocin infusion to reduce uterine contractions.
3. A client in labor has late fetal heart rate decelerations. After positioning the client on her
left side and administering oxygen, the nurse should perform which of the following next?
A. Palpate the uterus for contractions.
B. Increase the oxytocin infusion rate.
C. Insert an internal fetal scalp electrode.
D. Perform a vaginal examination to rule out a prolapsed cord.
Answer: A [CORRECT]
Rationale: While immediate interventions (position change, oxygen, stopping oxytocin) are
taken, the nurse must simultaneously assess the uterus for contraction frequency and
intensity (hyperstimulation) which may be compromising placental blood flow. Increasing
oxytocin is contraindicated. Internal monitoring is not the immediate priority over stabilizing
the fetus.
4. Which of the following nursing actions is appropriate when late decelerations are noted on
the fetal monitor? (Select all that apply.)
A. Turn the mother to the left lateral position.
, 3
B. Administer oxygen via a non-rebreather mask at 8 to 10 L/min.
C. Discontinue the oxytocin infusion if running.
D. Encourage the mother to push with contractions.
E. Prepare for an immediate amniotomy.
Answer: A, B, C [CORRECT]
Rationale: Late decelerations require interventions to improve uteroplacental perfusion:
turning the mother to the left side relieves pressure on the vena cava, oxygen administration
increases maternal oxygen saturation, and discontinuing oxytocin reduces uterine activity that
may be compromising blood flow. Pushing or rupturing membranes would increase stress on
the fetus.
5. The nurse is caring for a laboring client with epidural anesthesia. The fetal heart rate shows
late decelerations. The nurse recognizes that the primary physiological cause of these
decelerations is:
A. Fetal head compression.
B. Umbilical cord compression.
C. Uteroplacental insufficiency.
D. Fetal hypoxia due to maternal fever.
Answer: C [CORRECT]
Rationale: Late decelerations are caused by uteroplacental insufficiency, where the placenta is
not exchanging oxygen and carbon dioxide efficiently enough to meet fetal demands during
contractions. This often occurs due to maternal hypotension (a side effect of epidural
anesthesia), which reduces blood flow to the placenta.
, 4
6. The nurse assesses a client 1 hour after a vaginal delivery and finds the fundus to be boggy,
soft, and displaced to the right of the umbilicus. What is the priority nursing intervention?
A. Document the finding and reassess in 30 minutes.
B. Encourage the client to ambulate to the bathroom.
C. Massage the uterine fundus until it is firm and expel any clots.
D. Administer a prescribed analgesic for pain relief.
Answer: C [CORRECT]
Rationale: A boggy (soft) uterus displaced to the right usually indicates a full bladder
preventing the uterus from contracting, or retained placental fragments/clots. The immediate
intervention is fundal massage to stimulate uterine contraction (myometrium firmness) and
expel any pooled blood to prevent postpartum hemorrhage. The bladder should be emptied
afterward.
7. A postpartum client has a fundus that is boggy and 2 fingerbreadths above the umbilicus.
Which of the following actions should the nurse take? (Select all that apply.)
A. Perform firm uterine massage.
B. Assess for bladder distention.
C. Administer methylergonovine (Methergine) if prescribed and blood pressure is stable.
D. Encourage oral fluid intake.
E. Place the client in the Trendelenburg position.
Answer: A, B, C [CORRECT]
Rationale: A boggy uterus indicates atony and risk of hemorrhage. Interventions include
uterine massage to stimulate contraction, assessing for a distended bladder (which prevents
contraction), and administering uterotonic agents like Methergine if ordered. While fluids are
