Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
A. Fetal hypoxemia.
Fetal hypoxemia is associated with late decelerations in the fetal heart rate (FHR) tracing. It occurs when the fetus experiences a decreased supply of oxygen, typically due to placental insufficiency or maternal hypotension.
B. Cord compression.
Cord compression can lead to variable decelerations in the FHR tracing. It occurs when the umbilical cord is compressed, restricting blood flow to the fetus temporarily.
C. Uteroplacental insufficiency.
Uteroplacental insufficiency causes late decelerations in the FHR tracing. It refers to an inadequate blood flow between the uterus and placenta, resulting in reduced oxygen supply to the fetus.
D. Head compression.
Head compression is the correct answer for early decelerations in the FHR tracing. It happens during contractions when the fetal head is compressed by the maternal pelvis, leading to a temporary vagal response that slows the heart rate.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Fetal hypoxemia is associated with late decelerations in the fetal heart rate (FHR) tracing. It occurs when the fetus experiences a decreased supply of oxygen, typically due to placental insufficiency or maternal hypotension.
Choice B rationale:
Cord compression can lead to variable decelerations in the FHR tracing. It occurs when the umbilical cord is compressed, restricting blood flow to the fetus temporarily.
Choice C rationale:
Uteroplacental insufficiency causes late decelerations in the FHR tracing. It refers to an inadequate blood flow between the uterus and placenta, resulting in reduced oxygen supply to the fetus.
Choice D rationale:
Head compression is the correct answer for early decelerations in the FHR tracing. It happens during contractions when the fetal head is compressed by the maternal pelvis, leading to a temporary vagal response that slows the heart rate.
Similar Questions
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
A. A client who gave birth 1 day ago and needs Rh(D) immune globulin.
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
B. A client who gave birth 3 days ago and reports breast fullness.
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
C. A client who gave birth 12 hr ago and reports an increase in urinary output.
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
D. A client who gave birth 8 hr ago and is saturating a perineal pad every hour.
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
Full Explanation
Choice A rationale:
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
Choice B rationale:
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
Choice C rationale:
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
Choice D rationale:
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
A. Premature ovarian failure.
Premature ovarian failure affects the ovaries and leads to early menopause, resulting in the loss of the woman's reproductive ability. This condition can cause infertility due to the depletion or dysfunction of eggs in the ovaries, hindering conception.
B. Renal calculi.
Renal calculi (kidney stones) do not directly impact fertility. It is a condition unrelated to the reproductive system.
C. Dysmenorrhea.
Dysmenorrhea refers to painful menstruation and, while it can be uncomfortable, it does not necessarily affect fertility.
D. Recurrent urinary tract infections.
Recurrent urinary tract infections may be a concern for overall health but do not necessarily directly impact fertility unless there are severe complications. They are unrelated to infertility assessment.
Full Explanation
Choice A rationale:
Premature ovarian failure affects the ovaries and leads to early menopause, resulting in the loss of the woman's reproductive ability. This condition can cause infertility due to the depletion or dysfunction of eggs in the ovaries, hindering conception.
Choice B rationale:
Renal calculi (kidney stones) do not directly impact fertility. It is a condition unrelated to the reproductive system.
Choice C rationale:
Dysmenorrhea refers to painful menstruation and, while it can be uncomfortable, it does not necessarily affect fertility.
Choice D rationale:
Recurrent urinary tract infections may be a concern for overall health but do not necessarily directly impact fertility unless there are severe complications. They are unrelated to infertility assessment.
A nurse is caring for a client who is pregnant for the fourth time. The client delivered two full- term newborns and had one spontaneous abortion at 10 weeks of gestation. The nurse should document the client's obstetrical history as which of the following?
A. Gravida 3, Para 2.
Gravida refers to the number of times a woman has been pregnant, and Para indicates the number of pregnancies that have reached viability (at least 20 weeks) Since the client has been pregnant for the fourth time and delivered two full-term newborns (reached viability), she is gravida 4, and since she had one spontaneous abortion (miscarriage) at 10 weeks of gestation, she is para 2 (two pregnancies reached viability)
B. Gravida 3, Para 3.
This choice would be incorrect because it indicates that the client has had three pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.
C. Gravida 4, Para 2.
This is the correct choice, as explained above.
D. Gravida 4, Para 3.
This choice would be incorrect because it indicates that the client has had four pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.
Full Explanation
Choice A rationale:
Gravida refers to the number of times a woman has been pregnant, and Para indicates the number of pregnancies that have reached viability (at least 20 weeks) Since the client has
been pregnant for the fourth time and delivered two full-term newborns (reached viability), she is gravida 4, and since she had one spontaneous abortion (miscarriage) at 10 weeks of gestation, she is para 2 (two pregnancies reached viability)
Choice B rationale:
This choice would be incorrect because it indicates that the client has had three pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.
Choice C rationale:
This is the correct choice, as explained above. Choice D rationale:
This choice would be incorrect because it indicates that the client has had four pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.