Question

21. The nurse is assessing the fetal station during a vaginal examination. Which of the
following structures should the nurse palpate?
A. Sacral promontory
B. Ischial spines
C. Cervix
D. Symphysis pubis

22. When performing Leopold’s maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Where should the nurse place a fetoscope best to hear the fetal heart beat?
A. Left upper quadrant.
B. Right upper quadrant.
C. Left lower quadrant.
D. Right lower quadrant.

23. A woman has just arrived at the labor and delivery suite. In order to report the
client’s status to her primary health care practitioner, which of the following assessments should the nurse perform? Select all that apply.
A. Fetal heart rate.
B. Contraction pattern.
C. Contraction stress test.
D. Vital signs.
E. Biophysical profile.

24. A nurse is teaching a class of pregnant couples the most therapeutic breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach?
A. Alternately panting and blowing.
B. Rapid, deep breathing.
C. Grunting and pushing with contractions.
D. Slow chest breathing

25. The nurse auscultates a fetal heart rate of 150 on a client in early labor. Which of the following actions by the nurse is appropriate?
4 / 7
A. Inform the mother that the rate is normal.
B. Reassess in 5 minutes to verify the results.
C. Immediately report the rate to the health care practitioner.
D. Place the client on her left side and apply oxygen by face mask.

26. The nurse documents in a laboring woman’s chart that the fetal heart is being “assessed via intermittent auscultation.” To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times?
A. After every contraction.
B. For 10 minutes every half hour.
C. Periodically during the peak of contractions.
D. For 1 minute immediately after contractions

27. While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time?
A. The relationship between the decelerations and the labor contractions.
B. The maternal blood pressure.
C. The gestational age of the fetus.
D. The placement of the fetal heart electrode in relation to the fetal position.

28. An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure?
A. Maternal blood pressure.
B. Maternal pulse.
C. Fetal heart rate.
D. Fetal fibronectin level.

29. The fundal height of the woman is 30 cm and the fetus is engaged. What is the estimated fetal weight?
A. 2790 grams
B. 2945 grams
C. 3000 grams
D. 3100 grams

30. A patient is in transition phase. How frequently should you check or assess the perineum?
A. Every 5 minutes
B. Every 15 minutes
C. Every 30 minutes
D. Every 60 minutes

Answer 1

21.Ischial spines

station is asses by palpating the ischial spines

22. Left Lower Quadrant.

The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.

23. Fetal heart rate.
Contraction pattern.
Vital signs.

The nurse should assess the fetal heart before reporting the client's status to the healthcare provider.
-The nurse should assess the contraction pattern before reporting the client's status.
-The nurse should assess the woman's vital signs before reporting her status.

24.Slow chest breathing

Most women find slow chest breathing effective during the latent phase