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A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse?
- A. Correctly identifying abnormal FHR patterns and prescribing medication
- B. Correctly identifying abnormal FHR patterns and notifying the health care provider
- C. The nurse is not legally responsible for fetal monitoring
- D. Providing technical assessment to the monitor technicians
Correct Answer: B
Rationale: Nurses are responsible for the timely notification of the primary caregiver in the event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order.
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The patient's membranes have just ruptured. What is the first priority of the nurse?
- A. Turn the patient on the left side.
- B. Perform a Nitrazine test.
- C. Check the fetal heart rate (FHR).
- D. Perform a vaginal examination.
Correct Answer: C
Rationale: The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby.
Why is oxytocin administered in the third stage of labor?
- A. To stimulate lactation
- B. To relieve postpartum pain
- C. To stimulate uterine contractions
- D. To sedate the mother so she can rest
Correct Answer: C
Rationale: Oxytocin makes the uterus contract and reduces postpartum hemorrhage.
What is the largest diameter of the fetal skull?
- A. Temporal
- B. Biparietal
- C. Lateral
- D. Frontal-occipital
Correct Answer: B
Rationale: The largest transverse diameter of the fetal skull is the biparietal measurement. If this is too large, the skull may not be able to enter the mother's pelvis.
Which type of monitor will assess the intensity of contractions?
- A. External monitor
- B. Fetal monitor
- C. Maternal monitor
- D. Internal monitor
Correct Answer: D
Rationale: Internal monitoring is used to monitor the intensity of contractions, the frequency and duration of contractions, and the resting tone of uterine contractions. An external monitor is used to monitor the fetal heart rate and uterine activity.
The nurse is trying to differentiate true labor from false labor. Which of the following is correct regarding true labor?
- A. Discomfort of the contraction is in the fundus.
- B. Contractions do not follow a pattern.
- C. Contractions get stronger with ambulation.
- D. Contractions may stop with ambulation.
Correct Answer: C
Rationale: Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of regular, rhythmic contractions.