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 C

Explanation

A. "There is an increased risk of introducing infection." – While infections can occur, the primary concern with internal examinations in placenta previa is hemorrhage rather than infection.

B. "There is an increased risk of rupture of the membranes." – While membrane rupture is a risk with any vaginal examination, it is not the primary concern in placenta previa.

C. "This could result in profound bleeding." – With placenta previa, the placenta partially or completely covers the cervix. Digital or speculum exams can disrupt the placenta, causing significant hemorrhage, which is why they are contraindicated.

D. "This could initiate preterm labor." – While stimulation of the cervix could lead to contractions, the primary risk with an internal exam in placenta previa is significant bleeding, not preterm labor.

A. Feeling anxious about the baby's health and well-being, but still able to care for the baby effectively B. Experiencing occasional mood swings and irritability while adjusting to the new role of motherhood C. Feeling overwhelmed and having difficulty sleeping due to the demands of a newborn D. Persistent feelings of sadness, severe fatigue, and loss of interest in activities, including caring for the baby

Correct Answer is D

Explanation

A. Feeling anxious about the baby's health and well-being, but still able to care for the baby effectively
Mild anxiety about the baby’s health is a common experience for new mothers and does not necessarily indicate PPD. It becomes concerning if anxiety becomes overwhelming or interferes with daily functioning.

B. Experiencing occasional mood swings and irritability while adjusting to the new role of motherhood
Mood swings and irritability are normal postpartum adjustments, often due to hormonal changes, sleep deprivation, and new responsibilities. These symptoms typically resolve within a few weeks.

C. Feeling overwhelmed and having difficulty sleeping due to the demands of a newborn
Feeling overwhelmed and sleep disturbances are common in the postpartum period due to frequent infant care needs. However, severe or persistent sleep disturbances, especially with loss of interest in daily activities, may indicate PPD.

D. Persistent feelings of sadness, severe fatigue, and loss of interest in activities, including caring for the baby
Postpartum depression is characterized by prolonged sadness, extreme fatigue, withdrawal, and difficulty bonding with the baby. These symptoms extend beyond normal postpartum blues (which typically resolve within two weeks) and require medical intervention, including therapy and possibly medication.

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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 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?

Correct Answer is C

Explanation

A nurse is assessing a postpartum client for signs of postpartum depression. Which of the following symptoms is most indicative of postpartum depression rather than normal postpartum adjustment?

Correct Answer is D

Explanation

A nurse is reviewing the differences between placenta previa and abruptio placentae with a group of nursing students. Which of the following statements accurately differentiates placenta previa from abruptio placentae?

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A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

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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?