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Worksheets2205 Exam 2 pt.1
Total questions: 98
Worksheet time: 49mins
A nurse reviews an EFM strip: baseline 145, moderate variability, no decelerations, no accelerations in 20 minutes. The client reports the fetus “is usually sleepy.” What is the best next nursing action?
Extend monitoring for an additional 20 minutes before escalating testing
Turn off oxytocin and begin a fluid bolus
Prepare the client for emergent cesarean delivery
Administer 10 L O2 via non-rebreather immediately
A client receiving oxytocin develops 6 contractions in 10 minutes with recurrent variable decelerations. What is the priority nursing action?
Apply a fetal scalp electrode
Reposition the client to a lateral position
Perform fetal scalp stimulation
Increase oxytocin to shorten labor
The nurse notes late decelerations that begin after the peak of each contraction and recover after the contraction ends. Which cause is most consistent with this pattern?
Fetal head compression
Umbilical cord compression
Uteroplacental insufficiency
Fetal movement/response to stimulation
A strip shows an abrupt drop to the nadir within 30 seconds with a “V” shape and quick return to baseline, repeatedly. Which condition is the nurse most concerned about?
Placental abruption
Maternal hyperventilation
Fetal sleep cycle
Umbilical cord compression
A laboring client with an epidural suddenly becomes hypotensive and the fetus develops recurrent late decelerations. What is the nurse’s priority action?
Reposition the client (left lateral or side-to-side)
Administer a tocolytic immediately
Prepare for operative vaginal delivery
Perform a vaginal exam to assess dilation first
Which fetal heart rate finding most supports chorioamnionitis/intraamniotic infection?
Baseline 120 with accelerations
Fetal tachycardia sustained >10 minutes
Early decelerations with each contraction
Moderate variability with no decelerations
A nurse is teaching a student the mnemonic “VEAL CHOP.” Which pair is correctly matched?
Variable—Head compression
Early—Placental insufficiency
Acceleration—Okay
Late—Cord compression
Which EFM strip meets Category III criteria?
Moderate variability with recurrent variable decelerations
Minimal variability with accelerations
Tachycardia with moderate variability
Absent variability with recurrent late decelerations
A client at 35 weeks is admitted with preterm labor and cervical change. Which provider order is most important to prepare for fetal lung maturity?
Administer antenatal corticosteroids as prescribed
Start oxytocin to shorten exposure time
Perform frequent vaginal exams for progression
Encourage nipple stimulation to strengthen contractions
Which statement best describes a prolonged deceleration?
A gradual decrease that mirrors the contraction
An abrupt decrease lasting <30 seconds
A decrease lasting >2 minutes but <10 minutes
A smooth, wave-like pattern lasting ≥20 minutes
The nurse suspects cord prolapse after amniotomy because the fetus has sudden persistent bradycardia. What is the priority nursing action?
Call the provider after applying oxygen
Prepare the client for forceps delivery
Place the client in high-Fowler’s for gravity
Manually elevate the presenting part off the cord
A client is having an external cephalic version (ECV). Which complication requires the nurse to be ready for immediate intervention?
Maternal insomnia
Mild fetal hiccups
Placental abruption
Increased appetite after the procedure
A nurse is documenting rupture of membranes using the “COAT/COACH” approach. Which documentation entry best matches the “C” component?
“Fluid is clear, no particulate noted.”
“Client denies fever and chills.”
“Contractions every 3–4 minutes.”
“Cervix 6 cm/80%/0 station.”
A client with PPROM reports “a constant trickle.” Which test result most strongly supports amniotic fluid on microscopy?
Ferning pattern present
Elevated WBC count alone
Fetal fibronectin positive
Cervical length 4.5 cm
A nurse is evaluating a contraction pattern. Which finding meets tachysystole criteria?
5 contractions in 10 minutes with adequate resting tone
4 contractions in 10 minutes with late decelerations
6 contractions in 10 minutes, averaged over 30 minutes
2 contractions in 10 minutes with strong intensity
A nurse sees early decelerations that mirror contractions with moderate variability. What is the appropriate action?
Continue routine care and document findings
Administer a 500 mL IV fluid bolus
Stop oxytocin and notify the provider urgently
Apply 10–12 L O2 via non-rebreather immediately
Which finding is the best indicator of fetal well-being on an EFM strip?
Recurrent early decelerations
Moderate baseline variability
Baseline 110 exactly
Absence of accelerations for 20 minutes
A fetus has tachycardia 170 for 12 minutes. Which maternal condition is the nurse most suspicious of?
Maternal hypothermia
Maternal bradycardia
Intraamniotic infection
Rapid fetal descent at crowning
A client has variable decelerations and oligohydramnios. Which intervention may be prescribed to reduce cord compression?
Amnioinfusion
Dinoprostone cervical ripening
Fundal massage
Trendelenburg positioning only
A nurse is preparing to place an internal monitor. Which device directly measures uterine contraction intensity and resting tone numerically?
IUPC
External tocodynamometer
Doppler ultrasound only
Fetal scalp electrode
Which statement about fetal scalp electrode (FSE) placement is accurate?
It measures contraction intensity directly
It provides continuous fetal ECG-like heart rate tracing
It is the first-line tool for low-risk labor
It replaces the need to palpate contractions
A nurse reviews an EFM strip: baseline 100 for 15 minutes. Which interpretation is most accurate?
Fetal bradycardia baseline change is present
Normal baseline with sleep cycle
Category I by definition
Expected response to maternal pushing only
The nurse recognizes Category I fetal heart tracing includes which deceleration type?
Variable decelerations only
Late decelerations only
Early decelerations may be present
Prolonged decelerations are expected
A provider plans amniotomy. Which assessment is highest priority before the procedure?
Determine if the presenting part is engaged
Ask about nausea and heartburn
Confirm the client last ate solid food
Obtain a postpartum hemorrhage history
A client with minimal variability and no accelerations is suspected to be in a fetal sleep cycle. What is the best nursing action first?
Initiate an emergent C-section
Continue monitoring and consider gentle stimulation per protocol
Administer magnesium sulfate
Turn off oxytocin even if not infusing
Which complication is most associated with vacuum extraction or forceps that can later contribute to newborn jaundice?
Bruising/hematoma leading to increased bilirubin
Meconium aspiration syndrome
Neural tube defect
Necrotizing enterocolitis
A client’s membranes ruptured and the fluid is thick, chunky green. What is the priority nursing action?
Document and continue routine care only
Perform fetal scalp stimulation immediately
Increase oxytocin to expedite delivery
Notify the neonatal resuscitation team and prepare for newborn support
Which statement best differentiates induction from augmentation?
Induction strengthens contractions already present; augmentation starts labor
Induction starts labor; augmentation improves an ineffective labor pattern
Both terms mean the same thing clinically
Augmentation is only mechanical; induction is only medication
A nurse suspects uterine rupture during a TOLAC (trial of labor after cesarean). Which finding is most concerning?
Gradual increase in contraction strength
Mild fetal tachycardia for 5 minutes
Intermittent early decelerations
Sudden severe abdominal pain with abnormal FHR and loss of station
A client is being screened at 36 weeks. Which test is the standard routine screen in late pregnancy relevant to intrapartum care?
Group B Streptococcus (GBS) culture
Quad screen
Amniocentesis for karyotype
Newborn bilirubin level
A nurse sees recurrent late decelerations. After repositioning and IV fluid bolus, they persist. What is the next best action?
Turn off oxytocin (if infusing) and notify provider
Perform Leopold maneuvers
Encourage the client to hold breath and push through contractions
Begin amniotomy to speed delivery
The nurse is choosing pain management. Which is an expected complication of epidural anesthesia that can affect fetal status?
Maternal hypotension causing decreased placental perfusion
Maternal hyperthermia causing bradycardia
Increased uterine tone causing more oxygen delivery
Immediate placental abruption in all clients
A client is in the first stage of labor and asks why the fetus has “less breathing movements.” Which response is best?
“The fetus stops breathing completely once labor starts.”
“Labor can temporarily reduce fetal breathing movements as part of normal adaptation.”
“It means the fetus is acidotic and needs delivery now.”
“It only happens in breech presentations.”
A provider orders fetal fibronectin (fFN). Which client statement would require the nurse to notify the provider before collecting the specimen?
“I urinated 30 minutes ago.”
“I ate breakfast an hour ago.”
“I had intercourse last night.”
“I feel the baby move a lot today.”
Which finding is most consistent with true labor rather than false labor?
Contractions stop with hydration and position change
Cervical change occurs with regular contractions
Discomfort only in the lower abdomen without pattern
Contractions are irregular and do not intensify
A client is in active labor. Which assessment finding best supports active phase rather than latent phase?
Cervix 1 cm, irregular contractions
Cervix 3 cm, contractions every 10 minutes
Cervix 9 cm, urge to push
Cervix 6 cm with contractions becoming stronger and more regular
A nurse uses Leopold maneuvers primarily to determine which information?
Fetal lie, presentation, and position (including where the back is)
Placental maturity grading
Estimated fetal lung maturity
Umbilical cord pH
A nurse identifies a sinusoidal fetal heart rate pattern lasting over 20 minutes. What is the priority interpretation?
Benign head compression
Maternal dehydration only
Severe fetal anemia/hemorrhage risk—emergent situation
Fetal sleep cycle—reassess in an hour
Which nursing action is contraindicated during an active deceleration episode when considering fetal scalp stimulation?
Avoid scalp stimulation because it may worsen vagal response during decels
Provide a small fluid bolus
Reposition the client
Reduce uterine stimulation if present
A client has PPROM at 33 weeks. What is the priority nursing focus?
Frequent vaginal exams to trend dilation
Preventing ascending infection and monitoring for cord compression
Immediate induction with oxytocin in all cases
Discharge home without follow-up if afebrile
A client with suspected intraamniotic infection has a fever and uterine tenderness. What is the primary treatment?
IV antibiotics as prescribed
Continuous oxygen at 12 L NRB
Strict bed rest only
Tocolytics to stop labor indefinitely
A client is attempting VBAC. Which criterion is most important for safety?
Prior classical (vertical) uterine incision
No access to emergency surgical team
Prior uterine rupture history
Prior low transverse uterine incision with ability for emergency C-section
A fetus develops recurrent variables after rupture of membranes. Which mechanism best explains the change?
Loss of cushioning increases cord compression risk
Increased fetal breathing movements cause decels
Maternal hyperventilation causes placental insufficiency
Fetal scalp electrode placement causes lates
Which fetal presentation is most associated with increased risk of cord prolapse after amniotomy if the head is high?
Vertex, engaged
Breech or unengaged presenting part
Occiput anterior at +2 station
Fully crowned vertex
A nurse is teaching about stages of labor. Which statement is correct?
Second stage begins at 8 cm
Third stage is from 10 cm to birth
Second stage is from full dilation to birth of the baby
Fourth stage is the week after delivery
A nurse assesses postpartum recovery (fourth stage). Which finding requires the most immediate action?
Firm fundus at midline
Lochia rubra moderate
Bladder distention with boggy fundus
Mild perineal soreness
Which newborn care action is priority in the first minutes after birth?
Thermoregulation and airway/respiratory support assessment
Teaching about contraception
Delaying assessment until the placenta delivers
Bathing the newborn before drying
A nurse is assessing a strip with baseline 165 for 12 minutes. Which is the correct interpretation?
Normal baseline
Bradycardia
Tachycardia baseline change
Sinusoidal pattern
A client’s EFM shows Category II tracing with intermittent variables and moderate variability. What is the best nursing approach?
Continue close observation and implement intrauterine resuscitation as needed
Label as Category I because variability is moderate
Call for immediate emergent delivery without interventions
Discontinue all monitoring because it is indeterminate
Which fetal adaptation contributes to “molding” during labor?
Placental separation
Overlapping of fetal skull bones to fit the birth canal
Umbilical cord shortening
Increased fetal urine output
A nurse notes late decelerations and suspects uteroplacental insufficiency. Which maternal condition most strongly supports this cause?
Maternal hypertension
Maternal seasonal allergies
Maternal mild nausea
Maternal low back ache only
A client on oxytocin develops tachysystole. What is the priority nursing action?
Place the client supine to reduce movement
Perform an amniotomy
Increase oxytocin to overcome a dysfunctional pattern
Decrease or discontinue the oxytocin infusion per protocol
When using oxygen for intrauterine resuscitation, which nursing principle is most current evidence-based practice?
Oxygen is always the first step for any abnormal tracing
Use oxygen selectively and after other corrective measures
Use 2 L nasal cannula continuously throughout labor
Oxygen is contraindicated in all labor clients
Which diagnostic test is primarily used to assess fetal well-being by observing accelerations with fetal movement in a set time?
NST
Amniocentesis
Glucose tolerance test
Pap smear
A nonreactive NST is followed by which next test most commonly?
Maternal serum AFP
Biophysical profile (BPP)
Cervical length ultrasound only
Fern test
A contraction stress test (CST) is designed to evaluate fetal response to:
Maternal hydration status
Fetal breathing movements only
Uterine contractions (spontaneous or stimulated)
Maternal glucose levels
During second stage pushing, when should the nurse coach the client to push for maximal effectiveness?
The moment the contraction starts
Only between contractions
Immediately after the contraction ends
Near the peak of the contraction
Which statement about operative vaginal delivery is most accurate?
It eliminates the need for maternal pushing
It is used only in the first stage of labor
It is always safer than cesarean delivery
It can cause neonatal bruising/trauma and requires neonatal team readiness
Which medication is commonly used as a tocolytic in tachysystole management?
Terbutaline
Naloxone
Dinoprostone
Oxytocin
A nurse caring for a client in labor documents “station +1.” What does this indicate?
Presenting part is 1 cm above the ischial spines
Presenting part is at the level of the ischial spines
Presenting part is 1 cm below the ischial spines
Presenting part is crowning
The nurse is preparing for VBAC counseling. Which client statement shows correct understanding?
“If I had a classical incision, VBAC is usually preferred.”
“My hospital must be able to do an emergency C-section if needed.”
“Uterine rupture can’t happen once I’m in labor.”
“Continuous fetal monitoring isn’t needed during VBAC.”
A client in labor has recurrent variables despite repositioning. The provider orders amnioinfusion. Which nursing assessment is most important during the infusion?
Ensure adequate fluid return to avoid uterine overdistention
Encourage the client to ambulate continuously
Turn off all fetal monitoring to prevent artifact
Administer dinoprostone concurrently
A nurse suspects abruptio placentae. Which finding is most concerning?
Painless bright red bleeding with soft uterus
Sudden abdominal pain with a rigid/tender uterus and fetal distress
Clear amniotic fluid with ferning
Gradual cervical dilation with regular contractions
A client with suspected fetal demise asks what happens next. What is the priority nursing response?
Provide emotional support and discuss grief/loss resources while coordinating care
Avoid discussing the situation until the provider arrives
Tell the client to focus on future pregnancies only
Immediately discharge the client home for privacy
A client in preterm labor is receiving magnesium sulfate. Which fetal benefit is most associated with magnesium in early preterm labor?
Neuroprotection to reduce risk of neurologic injury
Prevents all neonatal jaundice
Eliminates need for corticosteroids
Increases fetal heart baseline variability permanently
A client receives nifedipine for preterm labor. The nurse explains it helps because it:
Increases uterine contractions
Is a calcium channel blocker that relaxes uterine muscle
Is a narcotic that reduces pain perception only
Is an antibiotic that treats GBS
Which assessment best supports Category I tracing?
Baseline 105 for 12 minutes
Recurrent late decelerations with minimal variability
Baseline 140 with moderate variability and no late/variable decelerations
Sinusoidal pattern
A client has recurrent late decelerations and absent variability. What is the best nursing expectation?
Continue oxytocin and recheck in 2 hours
This is Category II; observe only
Provide only comfort measures
Prepare for immediate intervention/emergent delivery
A nurse is assessing fetal presentation. Which is the most desirable position for vaginal birth?
Vertex/cephalic with occiput anterior
Face presentation mentum posterior
Breech frank with extended legs
Transverse lie
Which breech type involves hips flexed and knees extended (feet near head)?
Complete breech
Footling breech
Frank breech
Kneeling breech
A nurse recognizes “placental insufficiency” is most linked to which FHR change pattern?
Early decelerations
Late decelerations
Accelerations
Moderate variability
A client has meconium-stained fluid. Which newborn outcome is the nurse most concerned about if the infant is depressed at birth?
Meconium aspiration leading to respiratory distress
Hyperglycemia from steroids
Shoulder dystocia
Cord prolapse
Which maternal finding most increases risk for chorioamnionitis?
Prolonged rupture of membranes with frequent vaginal exams
Mild morning sickness
Occasional Braxton Hicks contractions
Early epidural placement at 1 cm
Which maternal sign supports intraamniotic infection requiring escalation?
Temperature 98.6°F (37°C) once
Uterine tenderness and fever with foul-smelling/purulent fluid
Clear fluid with no odor and normal vitals
Increased appetite and thirst only
A nurse prepares non-pharmacologic pain management. Which intervention is most appropriate during early labor?
Breathing/relaxation techniques and position changes/ambulation
Keep the client supine and restrict movement
Continuous breath-holding pushing practice
Avoid any education to reduce anxiety
The nurse administers IV opioid analgesia in labor. Which medication must be available to reverse maternal/newborn respiratory depression?
Nifedipine
Oxytocin
Dinoprostone
Naloxone
A nurse assesses the “5 Powers” affecting labor. Which set correctly lists them?
Passenger, Passageway, Powers, Position, Psyche
Placenta, Pain, Pelvis, Pushing, Psychology
Pressure, Presentation, Passage, Placenta, Pushing
Posture, Pulse, Pain, Power, Placental flow
Which sequence correctly matches key “cardinal movements” during vaginal birth (simplified)?
Extension → engagement → restitution → crowning
Engagement → descent → flexion → internal rotation → extension → external rotation
Descent → extension → engagement → flexion → expulsion
Internal rotation → engagement → descent → flexion
A client in third stage of labor is at high risk for hemorrhage. Which routine medication is commonly administered after delivery to help the uterus contract?
Oxytocin
Terbutaline
Nifedipine
Naloxone
After cesarean delivery, which nursing action best reduces risk of postoperative complications like DVT?
Keep the client on strict bed rest for 24 hours
Encourage early ambulation as soon as safe and use SCDs
Limit fluids to prevent edema
Avoid pain control to prevent sedation
A nurse is teaching about fetal heart rate baseline. Which range is considered normal?
80–120
90–140
110–160
120–180
A client’s fetus has persistent bradycardia despite interventions. What is the nurse’s priority preparation?
Prepare for emergency delivery
Encourage the client to walk
Administer dinoprostone
Delay action until accelerations appear
Which situation most increases risk for cord prolapse?
Engaged vertex at +1 station
Artificial rupture of membranes with a high, unengaged presenting part
Spontaneous rupture at crowning
Full dilation with occiput anterior
The nurse identifies a client has “dysfunctional labor.” Which description best fits?
Contractions are effective and cause progressive dilation
Cervical change occurs rapidly with descent
Contractions are ineffective with minimal progress in dilation/descent
Labor begins and ends within 2 hours
A nurse is preparing dinoprostone. What is the primary indication in intrapartum care?
Treat postpartum hemorrhage
Stop uterine contractions
Reverse opioid effects
Cervical ripening for induction of labor
Which finding suggests a non-reassuring fetal status that may require operative intervention if unresolved?
Moderate variability with accelerations
Absent variability with recurrent lates/prolonged decels
Early decelerations during pushing
Baseline 140 with no decelerations
A nurse is evaluating fetal presentation and finds a transverse lie late in pregnancy. What delivery plan is most likely?
Planned vaginal delivery without concern
Trial of labor with amniotomy early
Cesarean delivery if not corrected
Forceps delivery
A nurse is reviewing fetal assessment during labor. Which uterine stimulant is considered high-alert and requires careful titration?
Oxytocin
Ibuprofen
Acetaminophen
Ferrous sulfate
A client in labor has variable decelerations. Which cause is most consistent?
Maternal fever
Umbilical cord compression
Fetal head compression
Placental insufficiency
A nurse is assisting with a cord prolapse emergency. Which action must be avoided?
Keeping the presenting part elevated off the cord
Calling for immediate help and rapid response
Pinching or applying pressure to the umbilical cord
Positioning to reduce compression while maintaining manual elevation
A nurse is assessing fetal station. The presenting part is at the ischial spines. How is this documented?
0 station
+3 station
–3 station
+1 station
Which labor pain management method is categorized as regional anesthesia/analgesia?
Local perineal infiltration only
Nitrous oxide inhalation
Epidural anesthesia
IV opioid push
A client has PPROM. Which assessment finding suggests infection and requires prompt notification?
Clear, odorless fluid and normal vitals
Increased fetal movement and baseline 140
Mild back ache relieved by rest
Maternal fever with uterine tenderness and foul-smelling fluid
Which labor process complication is MOST likely to cause sudden, persistent fetal bradycardia?
Fetal hiccups
Cord prolapse
Normal fetal sleep cycle
Early decelerations from head compression
A nurse assesses Category III fetal tracing. Which component is required for Category III?
Absent variability with recurrent late/variable decelerations or bradycardia, OR sinusoidal pattern
Moderate variability with occasional variables
Baseline 110–160 with accelerations
Early decelerations with each contraction
A nurse is teaching about intermittent auscultation vs electronic fetal monitoring (EFM). Which statement is accurate?
Intermittent auscultation provides continuous contraction intensity values
EFM provides ongoing tracing to evaluate baseline, variability, and decelerations
Intermittent auscultation is preferred for all high-risk clients on oxytocin
EFM eliminates the need for any clinical assessment
A client’s fetus has minimal variability. Which is a common reason for loss of variability the nurse should consider first?
Fetal sleep cycle
Placental abruption always
Shoulder dystocia
Uterine rupture always
A nurse is prioritizing intrauterine resuscitation actions. Which sequence best reflects correct prioritization when abnormal tracing occurs?
Oxygen -> amnioinfusion -> reposition -> fluids
Fluids -> oxygen -> keep oxytocin running -> reposition
Reposition -> fluid bolus -> reduce uterine stimulation -> oxygen as last resort
Fetal scalp stimulation during late decels -> oxygen -> call provider
