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When observing the fetal heart monitor the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse?
- A. Early deceleration due to head compression
- B. That the fetus is in acute distress
- C. Variable decelerations due to cord compression
- D. That these are late decelerations
Correct Answer: A
Rationale: This indicates early decelerations because of head compression.
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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.
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.
For the first hour following delivery how often should the nurse assess the mother?
- A. Every 5 minutes
- B. Every 10 minutes
- C. Every 15 minutes
- D. Every 30 minutes
Correct Answer: C
Rationale: During the first hour, assessments are done every 15 minutes.
During the second stage of labor how often should the nurse monitor the fetal heart rate?
- A. Every 5 minutes
- B. Every 15 minutes
- C. Every 30 minutes
- D. Every hour
Correct Answer: A
Rationale: Fetal heart rate should be assessed every 5 minutes during the second stage of labor.
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.