External Maternal Monitoring

External Maternal Monitoring Related

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In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?

  • A. every 5 minutes with contractions
  • B. at least every 30 minutes
  • C. every 5–15 minutes
  • D. only when the physician orders assessment
Correct Answer: C

Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.

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A pregnant patient is at 34 weeks gestation and reports frequent headaches and visual changes. What should the nurse do first?

  • A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
  • B. Encourage the patient to rest and drink plenty of fluids.
  • C. Administer pain medication as prescribed to relieve the headache.
  • D. Schedule an appointment with an eye specialist to check for vision changes.
Correct Answer: A

Rationale: The correct answer is A. At 34 weeks gestation, headaches and visual changes can be signs of preeclampsia, a serious pregnancy complication. The nurse should first monitor the patient's blood pressure as elevated BP is a key indicator of preeclampsia. Assessing for other signs like proteinuria and edema is crucial for early detection and timely intervention. Encouraging rest and fluids (choice B) may not address the underlying issue. Administering pain medication (choice C) only masks symptoms without addressing the potential serious condition. Scheduling an eye specialist appointment (choice D) is not the priority as the symptoms are more indicative of a systemic issue like preeclampsia.

A 38-week gestation client, Bishop score 1, is advised by her nurse midwife to take evening primrose daily. The office nurse advises the client to report which of the following side effects that has been attributed to the oil?

  • A. Diarrhea.
  • B. Pedal edema.
  • C. Blurred vision.
  • D. Tinnitus.
Correct Answer: A

Rationale: Diarrhea is a known side effect of evening primrose oil. Pedal edema, blurred vision, and tinnitus are not typically associated with its use.

A nurse is preparing a laboring person for an epidural. What is the most important nursing action before the procedure?

  • A. ensure informed consent is signed
  • B. administer pain medication
  • C. administer IV fluids
  • D. administer an analgesic
Correct Answer: A

Rationale: The correct answer is A: ensure informed consent is signed. Before any procedure, obtaining informed consent is essential to ensure the laboring person understands the risks, benefits, and alternatives of the epidural. This helps promote autonomy and respect for the individual's decision-making. Administering pain medication (choice B), IV fluids (choice C), or an analgesic (choice D) without informed consent is not ethical and violates the principle of autonomy. The focus should be on providing comprehensive information and obtaining consent before proceeding with the intervention.

A woman whose prenatal weight was 105 lb weighs 109 lb at her 12-week visit. Which of the following comments by the nurse is appropriate at this time?

  • A. We expect you to gain about 1 lb per week, so your weight is a little low at this time.
  • B. Most women gain no weight during the first trimester, so I would suggest you eat fewer desserts for the next few weeks.
  • C. You entered the pregnancy well underweight, so we should check your diet to make sure you are getting the nutrients you need.
  • D. Your weight gain is exactly what we would expect it to be at this time.
Correct Answer: D

Rationale: A weight gain of 3 to 5 lb is expected during the first trimester. The client's weight gain is within the normal range.

A nurse is caring for a laboring person and is monitoring for signs of fetal distress. Which finding is the most concerning in this situation?

  • A. Late decelerations
  • B. Bradycardia
  • C. Tachycardia
  • D. Variable decelerations
Correct Answer: A

Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, which can lead to fetal hypoxia and distress. This is the most concerning finding as it indicates a problem with oxygen delivery to the fetus. Bradycardia (B) and Tachycardia (C) can also be concerning, but late decelerations are more specific to fetal distress. Variable decelerations (D) are caused by cord compression and are concerning but not as indicative of fetal distress as late decelerations.

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