Question

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no accelerations for 15 min. Which of the following actions should the nurse perform?

Answer 1

Correct Answers:

Offer the client a snack of orange juice and crackers.

Rationale :

💛During a nonstress test (NST), fetal accelerations reflect adequate oxygenation and fetal well-being.

💛Lack of accelerations for 15 minutes may indicate a nonreactive NST, often due to fetal sleep cycles or low maternal blood glucose.

💛Providing a carbohydrate snack (e.g., orange juice and crackers) raises maternal glucose levels, stimulating fetal activity and potentially converting the test to reactive.

💛This noninvasive intervention is performed before reporting to the provider.

💛The nurse continues monitoring and may use vibroacoustic stimulation if accelerations remain absent.

💛Reactivity after glucose intake supports normal fetal autonomic function and placental oxygen exchange.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Discontinue the medication infusion.

Rationale :

💜Magnesium sulfate acts as a CNS depressant and anticonvulsant in preeclampsia management but can reach toxic levels, causing loss of deep tendon reflexes (DTRs), respiratory depression, and oliguria.

💜Absent DTRs and reduced urine output (40 mL/2 hr) indicate toxicity and impaired excretion, requiring immediate discontinuation of the infusion.

💜The nurse must then notify the provider, monitor respirations, and prepare to administer calcium gluconate, the antidote for magnesium toxicity.

💜Continuous assessment of DTRs, respiratory rate, and urine output ensures early detection and prevention of respiratory arrest.

💜Safe magnesium levels are 4–7 mEq/L; exceeding this range suppresses reflexes and breathing.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Uteroplacental insufficiency

Rationale :

❤️Late decelerations on a fetal monitor occur after the peak of contractions and return to baseline after the contraction ends, indicating fetal hypoxia due to uteroplacental insufficiency.

❤️This means the placenta cannot deliver adequate oxygen during contractions.

❤️Immediate nursing actions include turning the mother to the left side, stopping oxytocin, providing oxygen, and increasing IV fluids to improve perfusion.

❤️Persistent late decelerations require prompt provider notification.

❤️Recognizing this pattern prevents fetal acidosis and distress.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Irregular contractions.

Rationale :

⏺️False labor (Braxton Hicks) is characterized by irregular, inconsistent contractions that do not increase in frequency, duration, or intensity over time.

⏺️These contractions do not cause cervical change—no progressive dilation or effacement—which is the key distinction from true labor.

⏺️Discomfort is often felt in the abdomen or groin and may resolve with rest, hydration, or position change.

⏺️In true labor, contractions become regular, closer together, stronger, and lead to measurable cervical change.

⏺️Teaching patients to note pattern, location of pain, and response to activity helps differentiate false from true labor and reduces unnecessary interventions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Naloxone

Rationale :

🟦Butorphanol (Stadol) is an opioid agonist–antagonist that can cause respiratory depression, especially when combined with other CNS depressants.

🟦Naloxone is a pure opioid antagonist that rapidly reverses opioid-induced respiratory depression by competitively displacing opioids at mu receptors.

🟦In laboring patients, naloxone dosing is titrated to restore adequate ventilation while minimizing abrupt analgesia loss; continuous monitoring is essential.

🟦If the medication was given close to birth, the newborn may also require neonatal naloxone for respiratory depression.

🟦After reversal, the nurse should reassess pain, provide nonpharmacologic support, and notify the provider to adjust the analgesia plan safely.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Administer misoprostol.

Rationale :

🟣In a hemodynamically stable early second-trimester spontaneous abortion, uterine evacuation is indicated to prevent retained products and complications.

🟣Misoprostol (PGE₁ analog) promotes cervical ripening and uterine contractions, enabling medical management without immediate surgery.

🟣It is effective, accessible, and allows predictable expulsion with careful pain control and infection surveillance.

🟣Regimens vary by gestational age and route (e.g., vaginal, sublingual), with counseling about expected bleeding and follow-up to confirm completion.

🟣The nurse monitors vital signs, bleeding, pain, and provides RhD immune globulin if indicated for Rh-negative clients.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Discontinue the infusion of the oxytocin

Rationale :

🔶Contractions every 2 minutes, lasting 95 seconds, and strong suggest uterine tachysystole with insufficient resting tone.

🔶The described uniform decelerations peaking after the contraction peak are consistent with late decelerations, indicating uteroplacental insufficiency.

🔶With late decelerations during oxytocin induction, the priority is to stop oxytocin to reduce uterine stimulation and restore fetal oxygenation.

🔶Next steps include maternal left lateral position, IV fluid bolus, oxygen as per protocol, and continuous fetal monitoring.

🔶The nurse must notify the provider after initiating intrauterine resuscitation and document the response before considering any further augmentation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Right upper

Rationale :

🟢A round, firm, movable part in the fundus is most consistent with the fetal head, indicating a breech presentation.

🟢The long, smooth, soft surface on the right side is the fetal back, which is the best site to hear fetal heart tones (FHTs).

🟢In breech, FHTs are usually heard above the umbilicus; with the back on the right, the optimal site is the right upper quadrant.

🟢Accurate identification with Leopold maneuvers improves monitor placement, FHR tracing quality, and clinical decision-making.

🟢Confirming presentation and back location reduces misinterpretation of fetal status and supports timely obstetric planning.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Forceps-assisted birth
Episiotomy

Rationale :

Forceps-assisted birth

✅ Operative vaginal delivery with forceps markedly increases risk of obstetric anal sphincter injury (OASIS) due to perineal traction and compressive forces.

✅ Force vectors during traction can extend perineal tears into the external and internal anal sphincters, especially in primiparas.

✅ Risk escalates with edematous tissues after prolonged labor and occiput posterior malpositions.

✅ Preventive strategies include judicious forceps use, correct application, and readiness for episiotomy only when indicated.

✅ Post-delivery care requires early recognition, expert repair, bowel regimen, and pelvic floor follow-up to reduce long-term dysfunction.

Episiotomy

✅A midline episiotomy increases the risk of third- and fourth-degree lacerations by creating a direct pathway toward the anal sphincter complex.

✅Extension is more likely with large infants, operative deliveries, and rapid crowning.

✅Current practice favors restrictive episiotomy (only for clear indications) and perineal support to minimize OASIS.

✅When episiotomy is performed, mediolateral technique may reduce anal sphincter involvement compared with midline.

✅Postpartum, meticulous assessment, pain control, stool softeners, and physiotherapy support healing and continence outcomes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Rigid, board-like abdomen
Vaginal bleeding
Severe abdominal pain
Frequent uterine contractions

Rationale :

Rigid, board-like abdomen

💎 A firm, tender, board-like abdomen is a classic hallmark of placental abruption caused by blood accumulation behind the placenta, leading to uterine muscle rigidity.

💎 This tone results from concealed hemorrhage, where blood becomes trapped between the uterine wall and placenta, increasing intrauterine pressure.

💎 Continuous monitoring and immediate intervention are critical to prevent maternal hypovolemic shock and fetal hypoxia.

💎 The nurse should assess fundal height, as it may rise due to concealed bleeding.

Vaginal bleeding

💎 Bleeding may be visible or concealed, depending on whether the placental separation is partial or complete.

💎 When visible, the blood is typically dark red and may occur without warning.

💎 The nurse should frequently assess the amount, color, and consistency of bleeding while avoiding vaginal examination until placental location is confirmed.

💎 This bleeding signals placental separation and poses significant fetal and maternal danger if untreated.

Severe abdominal pain

💎 Intense, constant abdominal or lower back pain occurs because of myometrial irritation from bleeding and placental detachment.

💎 Pain in abruption is sudden, sharp, and persistent, unlike the cramping nature of labor pain.

💎 The nurse should assess pain pattern, note fetal distress, and prepare for emergency delivery if indicated.

💎 Adequate analgesia and hemodynamic stabilization are priorities.

Frequent uterine contractions

💎 Hypertonic and frequent contractions result from uterine irritability due to blood infiltration into the myometrium.

💎 These contractions can further compromise placental perfusion, worsening fetal oxygen deprivation.

💎 Continuous fetal monitoring may show late decelerations or loss of variability—signs of fetal compromise.

💎 The nurse should discontinue oxytocin if running and notify the provider for immediate evaluation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no accelerations for 15 min. Which of the following actions should the nurse perform?

2 :
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 16/min and deep-tendon reflexes are absent, diuresis 40mL/2 hr. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

4 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets the following should the nurse recognize as a sign of false labor?

5 :
A nurse administers Stadol to a client in labor for pain management. The client begins to show symptoms of respiratory distress. Which of the following would be appropriate for the nurse to administer?

6 :
A nurse is caring for a client who is experiencing an early second-trimester spontaneous abortion and is hemodynamically stable. Which of the following prescriptions should the nurse expect the provider to prescribe?

10 :
A nurse is caring for a client who arrives at the labor and delivery unit. Which of the following findings should the nurse identify as potential manifestations of a placental abruption? Select All That Apply

QLexNursing

1 : A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no accelerations for 15 min. Which of the following actions should the nurse perform?

2 : A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 16/min and deep-tendon reflexes are absent, diuresis 40mL/2 hr. Which of the following actions should the nurse take?

3 : A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

4 : A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets the following should the nurse recognize as a sign of false labor?

5 : A nurse administers Stadol to a client in labor for pain management. The client begins to show symptoms of respiratory distress. Which of the following would be appropriate for the nurse to administer?

6 : A nurse is caring for a client who is experiencing an early second-trimester spontaneous abortion and is hemodynamically stable. Which of the following prescriptions should the nurse expect the provider to prescribe?

10 : A nurse is caring for a client who arrives at the labor and delivery unit. Which of the following findings should the nurse identify as potential manifestations of a placental abruption? Select All That Apply

1 :
A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no accelerations for 15 min. Which of the following actions should the nurse perform?

2 :
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 16/min and deep-tendon reflexes are absent, diuresis 40mL/2 hr. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

4 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets the following should the nurse recognize as a sign of false labor?

5 :
A nurse administers Stadol to a client in labor for pain management. The client begins to show symptoms of respiratory distress. Which of the following would be appropriate for the nurse to administer?

6 :
A nurse is caring for a client who is experiencing an early second-trimester spontaneous abortion and is hemodynamically stable. Which of the following prescriptions should the nurse expect the provider to prescribe?

10 :
A nurse is caring for a client who arrives at the labor and delivery unit. Which of the following findings should the nurse identify as potential manifestations of a placental abruption? Select All That Apply