Nokea
If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen?
- A. Right upper
- B. Left upper
- C. Right lower
- D. Left lower
Correct Answer: C
Rationale: When the fetus is in a right occiput anterior position, the back of the fetus is on the mother's right side, and the fetal heart is also located on the right side of the mother's abdomen. It is typically heard in the lower right quadrant due to the location of the fetal back and heart. The nurse should assess the fetal heart rate in the right lower quadrant of the maternal abdomen to accurately assess the well-being of the fetus in this position.
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The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.)
- A. Post-term fetus
- B. Maternal fever
- C. Placenta previa
- D. Induction of labor
Correct Answer: A
Rationale: A. Post-term fetus: Fetal scalp stimulation can be contraindicated in post-term fetuses due to the potential risks associated with uterine hyperstimulation and decreased fetal reserve in these pregnancies.
To clarify the fetal condition when baseline variability is absent, the nurse should first
- A. monitor fetal oxygen saturation using fetal pulse oximetry.
- B. notify the physician so that a fetal scalp blood sample can be obtaine
- C. apply pressure to the fetal scalp with a glove finger using a circular motion.
- D. increase the rate of nonadditive IV fluid to expand the mother's blood volume
Correct Answer: C
Rationale: When baseline variability is absent in fetal monitoring, it may indicate fetal hypoxia or acidemia. The appropriate action to further evaluate the fetal condition would be to notify the physician so that a fetal scalp blood sample can be obtained. This blood sample can provide important information about the oxygenation status of the fetus, helping to guide the management and interventions needed to support the baby's well-being. Monitoring fetal oxygen saturation using fetal pulse oximetry (choice A) or performing other interventions such as applying pressure to the fetal scalp (choice D) or increasing IV fluids for the mother (choice E) would not provide as direct or specific information about the fetal condition as obtaining a blood sample would.
A 26-year-old multigravida patient is 14 weeks pregnant and is scheduled for a maternal serum alpha-fetoprotein test. She asks the nurse, 'What does this test indicate?' The nurse explains that this test can detect which of the following?
- A. Leg defects
- B. Gastrointestinal defects
- C. Neural tube defects
- D. Renal defects
Correct Answer: C
Rationale: Quickening is the term used when a woman feels the first fetal movements. It typically happens around the second trimester and is a sign of fetal development and activity.
How often is oxytocin usually increased for induction or augmentation of labor?
- A. every 10 minutes
- B. every 30 minutes
- C. every 60 minutes
- D. every 90 minutes
Correct Answer: C
Rationale: Oxytocin is typically increased every 60 minutes during labor induction.
A patient is being prepared for an unplanned cesarean section. Which pre-procedure information is most important for the nurse to report before the administration of regional anesthesia?
- A. Hypovolemia corrected with IV fluid administration
- B. Inability of the patient to sit on the bedside and flex forward
- C. Laboratory value indicating a low platelet count
- D. History of patient experiencing headaches after a spinal
Correct Answer: C
Rationale: Choice C is the correct answer because a low platelet count indicates a risk for bleeding, and regional anesthesia can be dangerous in such cases due to the possibility of epidural or spinal hematoma.