Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?
A. Variability averages between 6 and 10 beats/min.
Variability refers to the fluctuations in the FHR that are irregular in amplitude and frequency. It reflects the balance between the sympathetic and parasympathetic nervous systems of the fetus. A normal variability is between 6 and 10 beats/min, which indicates a healthy and well-oxygenated fetus.
B. Mild late deceleration patterns occur with some contractions.
Late decelerations are decreases in the FHR that begin after the peak of a contraction and return to the baseline after the contraction ends. They are caused by uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. Mild late decelerations are not reassuring and may indicate fetal hypoxia or acidosis².
C. FHR does not change as a result of fetal activity.
FHR should change as a result of fetal activity, such as movement, sleep, or stimulation. A change in the FHR indicates a responsive and well-oxygenated fetus. A lack of change in the FHR may indicate fetal distress or compromise.
D. Average baseline rate ranges between 100 and 140 beats/min.
The average baseline rate is the mean FHR rounded to increments of 5 beats/min during a 10-minute window, excluding periods of marked variability, accelerations, or decelerations. A normal baseline rate is between 110 and 160 beats/min. A baseline rate between 100 and 140 beats/min is not necessarily abnormal, but it may indicate fetal bradycardia (slow heart rate) or tachycardia (fast heart rate), depending on the gestational age and other factors.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Midterm Proctored Exam 1. Take the full exam now
Full Explanation
Choice A reason: Variability refers to the fluctuations in the FHR that are irregular in amplitude and frequency. It reflects the balance between the sympathetic and parasympathetic nervous systems of the fetus. A normal variability is between 6 and 10 beats/min, which indicates a healthy and well-oxygenated fetus.
Choice B reason: Late decelerations are decreases in the FHR that begin after the peak of a contraction and return to the baseline after the contraction ends. They are caused by uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. Mild late decelerations are not reassuring and may indicate fetal hypoxia or acidosis².
Choice C reason: FHR should change as a result of fetal activity, such as movement, sleep, or stimulation. A change in the FHR indicates a responsive and well-oxygenated fetus. A lack of change in the FHR may indicate fetal distress or compromise.
Choice D reason: The average baseline rate is the mean FHR rounded to increments of 5 beats/min during a 10-minute window, excluding periods of marked variability, accelerations, or decelerations. A normal baseline rate is between 110 and 160 beats/min. A baseline rate between 100 and 140 beats/min is not necessarily abnormal, but it may indicate fetal bradycardia (slow heart rate) or tachycardia (fast heart rate), depending on the gestational age and other factors.
Similar Questions
How is fetal well-being during labor assessed?
A. An FHR greater than 110 beats/min.
An FHR greater than 110 beats/min is not a sufficient indicator of fetal well-being during labor. The normal range of FHR is between 110 and 160 beats/min, but it can vary depending on the gestational age, fetal activity, and maternal factors. A high or low FHR may indicate fetal distress or compromise.
B. Maternal pain control.
Maternal pain control is not a direct measure of fetal well-being during labor. However, maternal pain can affect the FHR indirectly by causing maternal stress, anxiety, or hyperventilation, which can alter the blood flow and oxygen delivery to the fetus. Therefore, adequate pain management is important for both maternal and fetal health.
C. The response of the FHR to UCs.
The response of the FHR to UCs is the most reliable and accurate way of assessing fetal well-being during labor. UCs can cause temporary reductions in the blood flow and oxygen supply to the fetus, which can affect the FHR. A normal response of the FHR to UCs is either no change or a slight increase (acceleration), which indicates a well-oxygenated and resilient fetus. An abnormal response of the FHR to UCs is a decrease (deceleration), which indicates a compromised or hypoxic fetus.
D. Accelerations in the FHR.
Accelerations in the FHR are not a definitive measure of fetal well-being during labor. Accelerations are transient increases in the FHR above the baseline, usually caused by fetal movement, stimulation, or UCs. Accelerations are generally reassuring and indicate a responsive and well-oxygenated fetus, but they are not always present or consistent. The absence of accelerations does not necessarily mean fetal distress, as some fetuses may have periods of sleep or reduced activity.
Full Explanation
Choice A reason: An FHR greater than 110 beats/min is not a sufficient indicator of fetal well-being during labor. The normal range of FHR is between 110 and 160 beats/min, but it can vary depending on the gestational age, fetal activity, and maternal factors. A high or low FHR may indicate fetal distress or compromise.
Choice B reason: Maternal pain control is not a direct measure of fetal well-being during labor. However, maternal pain can affect the FHR indirectly by causing maternal stress, anxiety, or hyperventilation, which can alter the blood flow and oxygen delivery to the fetus. Therefore, adequate pain management is important for both maternal and fetal health.
Choice C reason: The response of the FHR to UCs is the most reliable and accurate way of assessing fetal well-being during labor. UCs can cause temporary reductions in the blood flow and oxygen supply to the fetus, which can affect the FHR. A normal response of the FHR to UCs is either no change or a slight increase (acceleration), which indicates a well-oxygenated and resilient fetus. An abnormal response of the FHR to UCs is a decrease (deceleration), which indicates a compromised or hypoxic fetus.
Choice D reason: Accelerations in the FHR are not a definitive measure of fetal well-being during labor. Accelerations are transient increases in the FHR above the baseline, usually caused by fetal movement, stimulation, or UCs. Accelerations are generally reassuring and indicate a responsive and well-oxygenated fetus, but they are not always present or consistent. The absence of accelerations does not necessarily mean fetal distress, as some fetuses may have periods of sleep or reduced activity.
Which presumptive sign (felt by the woman) or probable sign (observed by the examiner) of pregnancy is not matched with another possible cause?
A. Quickening: Gas, peristalsis
Quickening is the first perception of fetal movement by the pregnant woman, usually felt between 16 and 20 weeks of gestation. However, quickening can also be confused with gas or peristalsis, which are normal digestive processes that cause sensations in the abdomen.
B. Chadwick sign: Pelvic congestion
Chadwick sign is a bluish discoloration of the cervix, vagina, and vulva due to increased blood flow during pregnancy. It can be observed by the examiner as early as 6 weeks of gestation. However, Chadwick sign can also be caused by pelvic congestion, which is a chronic condition of enlarged and dilated veins in the pelvis².
C. Amenorrhea: Stress, endocrine problems
Amenorrhea is the absence of menstrual periods, which is one of the most common signs of pregnancy. However, amenorrhea can also be caused by stress, endocrine problems, or other factors that affect the hormonal balance and ovulation.
D. Goodell sign: Cervical polyps
Goodell sign is the softening of the cervix due to increased vascularity and edema during pregnancy. It can be palpated by the examiner around 6 to 8 weeks of gestation. Goodell sign is not associated with any other condition besides pregnancy, unlike cervical polyps, which are benign growths of the cervical tissue that can cause bleeding or discharge.
Full Explanation
Choice A reason: Quickening is the first perception of fetal movement by the pregnant woman, usually felt between 16 and 20 weeks of gestation. However, quickening can also be confused with gas or peristalsis, which are normal digestive processes that cause sensations in the abdomen.
Choice B reason: Chadwick sign is a bluish discoloration of the cervix, vagina, and vulva due to increased blood flow during pregnancy. It can be observed by the examiner as early as 6 weeks of gestation. However, Chadwick sign can also be caused by pelvic congestion, which is a chronic condition of enlarged and dilated veins in the pelvis².
Choice C reason: Amenorrhea is the absence of menstrual periods, which is one of the most common signs of pregnancy. However, amenorrhea can also be caused by stress, endocrine problems, or other factors that affect the hormonal balance and ovulation.
Choice D reason: Goodell sign is the softening of the cervix due to increased vascularity and edema during pregnancy. It can be palpated by the examiner around 6 to 8 weeks of gestation. Goodell sign is not associated with any other condition besides pregnancy, unlike cervical polyps, which are benign growths of the cervical tissue that can cause bleeding or discharge.
What should a nurse know about the contraction stress test (CST) when providing care for the antepartum woman?
A. It sometimes uses vibroacoustic stimulation.
Vibroacoustic stimulation is a technique that uses sound to stimulate the fetus and elicit a response. It is sometimes used in conjunction with the nonstress test (NST), not the CST. The NST measures the fetal heart rate (FHR) in response to fetal movement, while the CST measures the FHR in response to uterine contractions.
B. It is considered negative if no late decelerations are observed with the contractions.
A negative CST result means that the FHR does not show any late decelerations during at least three contractions in a 10-minute period. Late decelerations are decreases in the FHR that begin after the peak of a contraction and return to the baseline after the contraction ends. They indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. A negative CST result is reassuring and suggests that the fetus is well-oxygenated and can tolerate labor².
C. It is an invasive test; however, contractions are stimulated.
The CST is not an invasive test, as it does not involve inserting any instruments or devices into the uterus or the fetus. However, it does require stimulating contractions, either by giving the pregnant woman oxytocin (a hormone that causes uterine contractions) or by having her rub her nipples (which also releases oxytocin). The contractions can be uncomfortable and may trigger preterm labor in some cases.
D. It is more effective than nonstress test (NST) if the membranes have already been ruptured.
The CST is not more effective than the NST if the membranes have already been ruptured. In fact, the CST is contraindicated (not recommended) in women who have ruptured membranes, as it can increase the risk of infection and bleeding. The NST is a safer and simpler alternative to the CST, as it does not require stimulating contractions. However, the NST may not be as reliable as the CST in detecting fetal compromise.
E. It is more effective than nonstress test (NST) if the membranes have already been ruptured.
Full Explanation
Choice A reason: Vibroacoustic stimulation is a technique that uses sound to stimulate the fetus and elicit a response. It is sometimes used in conjunction with the nonstress test (NST), not the CST. The NST measures the fetal heart rate (FHR) in response to fetal movement, while the CST measures the FHR in response to uterine contractions.
Choice B reason: A negative CST result means that the FHR does not show any late decelerations during at least three contractions in a 10-minute period. Late decelerations are decreases in the FHR that begin after the peak of a contraction and return to the baseline after the contraction ends. They indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. A negative CST result is reassuring and suggests that the fetus is well-oxygenated and can tolerate labor².
Choice C reason: The CST is not an invasive test, as it does not involve inserting any instruments or devices into the uterus or the fetus. However, it does require stimulating contractions, either by giving the pregnant woman oxytocin (a hormone that causes uterine contractions) or by having her rub her nipples (which also releases oxytocin). The contractions can be uncomfortable and may trigger preterm labor in some cases.
Choice D reason: The CST is not more effective than the NST if the membranes have already been ruptured. In fact, the CST is contraindicated (not recommended) in women who have ruptured membranes, as it can increase the risk of infection and bleeding. The NST is a safer and simpler alternative to the CST, as it does not require stimulating contractions. However, the NST may not be as reliable as the CST in detecting fetal compromise.