AND 100% CORRECT WELL DETAILED
The nurse notes persistent early decelerations on the fetal monitoring strip. Which action
would the nurse do next?
a) Stay with the client while reporting the finding to the primary care provider.
b) Administer oxygen after turning the client on her left side.
c) Continue to monitor the FHR because this pattern is benign.
d) Perform a vaginal exam to assess cervical dilation and effacement. - ANSWER c)
Continue to monitor the FHR because this pattern is benign.
Early decelerations are not indicative of fetal distress and do not require intervention.
Therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no
need to perform a vaginal exam, report the finding to the primary care provider, or
administer oxygen.
When applying the ultrasound transducers for continuous external electronic fetal
monitoring, the nurse would place the transducer to record the FHR at which location?
a) between the umbilicus and the symphysis pubis
b) between the xiphoid process and umbilicus
c) over the uterine fundus where contractions are most intense
d) above the umbilicus toward the right side of the diaphragm - ANSWER a) between
the umbilicus and the symphysis pubis
1
, The ultrasound transducer is positioned on the maternal abdomen in the midline between
the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus
in the area of greatest contractility.
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse
prepares the client for this monitoring based on the understanding that which criterion must
be present?
a) a neonatologist to insert the electrode
b) intact membranes
c) floating presenting fetal part
d) cervical dilation of 2 cm or more - ANSWER d) cervical dilation of 2 cm or more
For continuous internal electronic fetal monitoring, four criteria must be met: ruptured
membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow
placement of the electrode, and a skilled practitioner available to insert the electrode.
The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the
fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing
intervention?
a) Administer oxygen.
b) Increase her IV fluids.
c) Notify the primary care provider.
d) Change the position of the client. - ANSWER d) Change the position of the client.
Variable decelerations often indicate a type of cord compression. The initial response is to
change the position and try to release the cord compression. If this does not work, apply
oxygen while using the call light to alert others. If this continues, her fluid status needs to be
assessed before increasing her IV rate.
2
The nurse notes persistent early decelerations on the fetal monitoring strip. Which action
would the nurse do next?
a) Stay with the client while reporting the finding to the primary care provider.
b) Administer oxygen after turning the client on her left side.
c) Continue to monitor the FHR because this pattern is benign.
d) Perform a vaginal exam to assess cervical dilation and effacement. - ANSWER c)
Continue to monitor the FHR because this pattern is benign.
Early decelerations are not indicative of fetal distress and do not require intervention.
Therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no
need to perform a vaginal exam, report the finding to the primary care provider, or
administer oxygen.
When applying the ultrasound transducers for continuous external electronic fetal
monitoring, the nurse would place the transducer to record the FHR at which location?
a) between the umbilicus and the symphysis pubis
b) between the xiphoid process and umbilicus
c) over the uterine fundus where contractions are most intense
d) above the umbilicus toward the right side of the diaphragm - ANSWER a) between
the umbilicus and the symphysis pubis
1
, The ultrasound transducer is positioned on the maternal abdomen in the midline between
the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus
in the area of greatest contractility.
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse
prepares the client for this monitoring based on the understanding that which criterion must
be present?
a) a neonatologist to insert the electrode
b) intact membranes
c) floating presenting fetal part
d) cervical dilation of 2 cm or more - ANSWER d) cervical dilation of 2 cm or more
For continuous internal electronic fetal monitoring, four criteria must be met: ruptured
membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow
placement of the electrode, and a skilled practitioner available to insert the electrode.
The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the
fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing
intervention?
a) Administer oxygen.
b) Increase her IV fluids.
c) Notify the primary care provider.
d) Change the position of the client. - ANSWER d) Change the position of the client.
Variable decelerations often indicate a type of cord compression. The initial response is to
change the position and try to release the cord compression. If this does not work, apply
oxygen while using the call light to alert others. If this continues, her fluid status needs to be
assessed before increasing her IV rate.
2
