Nokea
A woman is admitted in active labor and the nurse assesses the fetal heart rate (FHR) at 124 beats/min. What action should the nurse take based on the assessment?
- A. Position patient on her left side.
- B. Start oxygen per nasal cannula.
- C. Reassure the mother the rate is normal.
- D. Notify the health care provider at once.
Correct Answer: C
Rationale: The normal FHR is 120 to 160 beats/min. No interventions are required.
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A woman who is 38 weeks' pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe?
- A. Lightening
- B. Braxton-Hicks contractions
- C. Initiation of labor
- D. Engagement
Correct Answer: A
Rationale: The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally.
What area of the uterus provides the force during a contraction?
- A. Lower portion
- B. Middle portion
- C. Upper portion
- D. Cervical portion
Correct Answer: C
Rationale: The upper portion of the uterus provides the force during contractions.
During labor the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse?
- A. Ask the husband to leave the room.
- B. Assure the husband that such behavior is normal.
- C. Remind the patient that the husband wants to help.
- D. Change the patient's position.
Correct Answer: B
Rationale: During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal.
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.
An infant presents 5 minutes after delivery with a heart rate of 105 crying has some flexion in the arms sneezes and has a pink body and blue limbs. What Apgar score should be assigned to this infant?
- A. 5
- B. 7
- C. 8
- D. 10
Correct Answer: C
Rationale: The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1; sneeze = 2; pink body, blue limbs = 1.