HSA NR222

1. The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? a. This pattern reflects variable decelerations. No interventions are necessary at this time. b. Document this Category I fetal heart rate pattern and decrease the rate of the intravenous (IV) fluid. c. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. d. This deceleration pattern is associated with uteroplacental insufficiency. The nurse must act quickly to improve placental blood flow and fetal oxygen supply. ANS: D A pattern similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction, describes a late deceleration. Oxygen should be given via a snug face mask. Position the patient on her left side to increase placental blood flow. Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. This is not a normal pattern, rather it is a Category III tracing, predictive of abnormal fetal acid status at the time of observation. The IV rate should be increased in order to add to the mother’s blood volume. These are late decelerations, not early; therefore interventions are necessary. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity 2. Which maternal condition should be considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix dilated to 4 cm c. Fetus has known heart defect d. Maternal HIV ANS: A To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm would permit the insertion of fetal scalp electrodes and an intrauterine catheter. A compromised fetus should be monitored with the most accurate monitoring devices. An internal electrode should not be placed if the patient has hemophilia, maternal HIV, or genital herpes. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity 3. The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? a. Doppler NURSINGTB.COM Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank NU RS IN GT B.CO M b. Fetoscope c. Scalp electrode d. Tocodynamometer ANS: A Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The tocodynamometer does not require gel. This device monitors uterine contractions. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 4. Proper placement of the tocotransducer for electronic fetal monitoring is a. Inside the uterus. b. On the fetal scalp. c. Over the uterine fundus. d. Over the mother’s lower abdomen. ANS: C The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use. The tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at the fundus; this is the best placement area. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 5. Which clinical finding can be determined only by electronic fetal monitoring? a. Variability b. Tachycardia c. Bradycardia d. Fetal response to contractions ANS: A Beat-to-beat variability cannot be determined by auscultation because auscultation provides only an average fetal heart rate (FHR) as it fluctuates. Tachycardia can be determined by any of the FHR monitoring techniques. Bradycardia can be determined by any of the FHR monitoring techniques. The fetal response to the contractions is usually noted by an increase or decrease in fetal heart rate. These can be determined by any of the FHR monitoring techniques.