While caring for a client in labor, which assessment finding best indicates fetal well-being to the nurse?

Presence of late decelerations with each contraction during monitoring

Increased fetal movement between contractions

Fetal heart rate of 160 beats per minute with moderate variability

Fetal heart rate consistently below 120 beats per minute with no accelerations

Answer and Explanation

The Correct Answer is C

A. "Presence of late decelerations with each contraction during monitoring."
Late decelerations indicate uteroplacental insufficiency, which can lead to fetal hypoxia and distress. This is not a reassuring sign.

B. "Increased fetal movement between contractions."
While fetal movement is a positive sign, it is not the best indicator of fetal well-being in labor. Continuous FHR monitoring provides a better assessment.

C. "Fetal heart rate of 160 beats per minute with moderate variability."
A normal fetal heart rate (FHR) is 110–160 bpm, and moderate variability (6–25 bpm fluctuations) indicates a well-oxygenated fetus with an intact autonomic nervous system.

D. "Fetal heart rate consistently below 120 beats per minute with no accelerations."
A persistent FHR below 110 bpm (bradycardia) or minimal variability suggests possible fetal compromise.

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Correct Answer is ["B","D","E"]

Explanation

A. Passage of fetal tissue – This finding is more consistent with an incomplete or complete abortion, not a threatened abortion.

B. Bright red vaginal bleeding – A threatened abortion involves vaginal bleeding during the first 20 weeks of pregnancy, often bright red in color. The cervix remains closed, and fetal cardiac activity may still be present.

C. Severe cramping and pelvic pain – Severe pain is more typical of an inevitable or incomplete abortion rather than a threatened abortion.

D. Closed cervix upon examination – In a threatened abortion, the cervix remains closed. If the cervix opens, the risk of progressing to an inevitable abortion increases.

E. Mild to moderate lower abdominal cramping – Mild cramping or lower abdominal discomfort is common in a threatened abortion due to uterine contractions. However, severe cramping and passage of fetal tissue would indicate a more advanced pregnancy loss.

A. During the next attempt to get pregnant B. Immediately after delivery C. During the third trimester of pregnancy D. During the first trimester of pregnancy

Correct Answer is B

Explanation

A. During the next attempt to get pregnant
This is incorrect because waiting until the next pregnancy increases the risk of congenital rubella syndrome in future pregnancies. The vaccine should be given immediately postpartum to provide immunity.

B. Immediately after delivery
This is correct because the rubella vaccine (MMR) is a live vaccine and is contraindicated during pregnancy due to teratogenic effects. It should be given postpartum before hospital discharge to prevent future rubella infections.

C. During the third trimester of pregnancy
This is incorrect because live vaccines are contraindicated in pregnancy due to the risk of fetal infection.

D. During the first trimester of pregnancy
This is incorrect because administering a live vaccine early in pregnancy is dangerous and could cause fetal harm or congenital anomalies.

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While caring for a client in labor, which assessment finding best indicates fetal well-being to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with a threatened abortion. Which assessment findings would the nurse expect? Select all that apply. (Select All that Apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a client in the first trimester of pregnancy and discovers that the client lacks immunity to rubella based on her blood work. When is the recommended time for administering rubella immunization?

Correct Answer is B

Explanation

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) The nurse will implement the following interventions based on the fetal heart rate.(Select All that Apply.)

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Exhibits Select a condition, the assessment cues, and anticipated solutions for this client.

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A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

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The nurse is reviewing fetal and maternal circulation with a group of nursing students. Which statement by a student demonstrates a need for further clarification?

A nurse is reviewing the different signs of pregnancy with a client who is in her first trimester. Which of the following symptoms should the nurse classify as a positive sign of pregnancy?