NUR 202 Mod F Questions With Complete
Solutions
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse
determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on
two occasions and 157 once during a 20-minute period. Each of the episodes in which
the heart rate is increased lasts 20 seconds. What action should the nurse take? –
answer Discontinuing the test because the pattern is within the expected rang
. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15
seconds during a 20-minute period
A woman at 39 weeks' gestation whose membranes have ruptured at home arrives at
the clinic to be evaluated. Assessment reveals mild irregular contractions 10 to 15
minutes apart and a fetal heart rate (FHR) of 186 beats/min is auscultated between
contractions. In light of this assessment, what does the nurse conclude? answer - A
further assessment is necessary
The fetal heart rate should be 110 to 160 beats/min; an FHR of 186 is tachycardic and
further evaluation is necessary because the fetus may be at risk.
As a means of halting preterm labor a client is started on terbutaline (Brethine). For
which side effect of this medication should the nurse monitor the client? answer -
Widening pulse pressure
,A widening pulse pressure is a side effect of terbutaline
A nurse is caring for a client in preterm labor who is receiving a course of corticosteroids
to promote fetal lung maturity. What test may be used to most accurately determine
fetal lung maturity? answer - Amniocentesis
A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. What
does the nurse suspect precipitated this preterm labor? - Incompetent cervix
An incompetent cervix indicates a short cervix, cervical scarring from previous births, or
cervical or uterine anomalies. It puts the client at risk for second-trimester miscarriage
A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether
there is any medication that can stop the contractions. What is the nurse's response? -
answer "A beta-adrenergic."
Beta-adrenergic medications are tocolytic agents that may halt labor, although only
temporarily.
A nurse places fetal and uterine monitors on the abdomen of a client in labor. While
observing the relationship between the fetal heart rate and uterine contractions, the
nurse identifies four late decelerations. What condition is most frequently associated
with late decelerations? answer - Uteroplacental insufficiency
Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental
insufficiency
, A client at 30 weeks' gestation is admitted in preterm labor. An intravenous solution of
the tocolytic agent ritodrine (Yutopar) is started. The nurse prepares to administer an
intramuscular injection of betamethasone (Celestone). The client asks why
betamethasone is being administered. The nurse responds, "It: - answer Stimulates
fetal lung maturity"
It stimulates the release of enzymes that produce lung surfactant, which promotes fetal
lung maturity
A client in labor is receiving an oxytocin (Pitocin) infusion. What should the nurse do first
when repetitive late decelerations of the fetal heart rate are observed? answer -
Discontinue the oxytocin infusion
The infusion should be stopped because it is the likely source of fetal compromise.
A client at 40 weeks' gestation is admitted to the birthing unit in early active labor.
During her intake assessment, she tells the nurse that her membranes ruptured 26
hours ago. Initial assessments of the fetal heart rate range between 168 and 174
beats/min. What is the priority nursing action? answer - Assessing maternal vital signs
A prolonged period after the rupture of membranes and fetal tachycardia indicate the
possibility of maternal infection; the maternal vital signs should be assessed for fever
and increased pulse and respirations
Solutions
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse
determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on
two occasions and 157 once during a 20-minute period. Each of the episodes in which
the heart rate is increased lasts 20 seconds. What action should the nurse take? –
answer Discontinuing the test because the pattern is within the expected rang
. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15
seconds during a 20-minute period
A woman at 39 weeks' gestation whose membranes have ruptured at home arrives at
the clinic to be evaluated. Assessment reveals mild irregular contractions 10 to 15
minutes apart and a fetal heart rate (FHR) of 186 beats/min is auscultated between
contractions. In light of this assessment, what does the nurse conclude? answer - A
further assessment is necessary
The fetal heart rate should be 110 to 160 beats/min; an FHR of 186 is tachycardic and
further evaluation is necessary because the fetus may be at risk.
As a means of halting preterm labor a client is started on terbutaline (Brethine). For
which side effect of this medication should the nurse monitor the client? answer -
Widening pulse pressure
,A widening pulse pressure is a side effect of terbutaline
A nurse is caring for a client in preterm labor who is receiving a course of corticosteroids
to promote fetal lung maturity. What test may be used to most accurately determine
fetal lung maturity? answer - Amniocentesis
A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. What
does the nurse suspect precipitated this preterm labor? - Incompetent cervix
An incompetent cervix indicates a short cervix, cervical scarring from previous births, or
cervical or uterine anomalies. It puts the client at risk for second-trimester miscarriage
A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether
there is any medication that can stop the contractions. What is the nurse's response? -
answer "A beta-adrenergic."
Beta-adrenergic medications are tocolytic agents that may halt labor, although only
temporarily.
A nurse places fetal and uterine monitors on the abdomen of a client in labor. While
observing the relationship between the fetal heart rate and uterine contractions, the
nurse identifies four late decelerations. What condition is most frequently associated
with late decelerations? answer - Uteroplacental insufficiency
Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental
insufficiency
, A client at 30 weeks' gestation is admitted in preterm labor. An intravenous solution of
the tocolytic agent ritodrine (Yutopar) is started. The nurse prepares to administer an
intramuscular injection of betamethasone (Celestone). The client asks why
betamethasone is being administered. The nurse responds, "It: - answer Stimulates
fetal lung maturity"
It stimulates the release of enzymes that produce lung surfactant, which promotes fetal
lung maturity
A client in labor is receiving an oxytocin (Pitocin) infusion. What should the nurse do first
when repetitive late decelerations of the fetal heart rate are observed? answer -
Discontinue the oxytocin infusion
The infusion should be stopped because it is the likely source of fetal compromise.
A client at 40 weeks' gestation is admitted to the birthing unit in early active labor.
During her intake assessment, she tells the nurse that her membranes ruptured 26
hours ago. Initial assessments of the fetal heart rate range between 168 and 174
beats/min. What is the priority nursing action? answer - Assessing maternal vital signs
A prolonged period after the rupture of membranes and fetal tachycardia indicate the
possibility of maternal infection; the maternal vital signs should be assessed for fever
and increased pulse and respirations
