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Chapter 9: Fetal Heart Rate Assessment

Multiple Choice

1. The nurse uses the external electronic fetal heart monitor to evaluate fetal status. The fetal heart
tracing shows accelerations. Accelerations in the fetal heart are:
a. Associated with fetal well-being and oxygenation b.
An indication of potential fetal intolerance to labor c.
Never associated with the uterine contraction pattern
d. A reason to notify the care provider

ANS: a
Feedback
a. Accelerations are a sign of fetal well-being.
b. Accelerations are a sign of fetal well-being and are reassuring.
c. Accelerations may or may not be associated with uterine contractions.
d. Accelerations are reassuring, and there is no need to notify the care provider.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

2. The nurse knows that a FHR monitor printout indicates a Category III abnormal fetal heart rate
pattern when:
a. Baseline variability is minimal or absent with decelerations.
b. FHR mirrors the uterine contractions.
c. Occasional periodic accelerations occur.
d. Baseline variability is 6 to 25 bpm with decelerations

ANS: a
Feedback
a. Minimal or absent baseline variability may be an indication of fetal hypoxia.
b. This answer describes early decelerations that are not an indication of fetal intolerance of labor.
c. Periodic accelerations are a sign of fetal well-being.
d. A baseline variability of 6 to 25 bpm is normal.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

3. As the nurse explains the purpose of the tocotransducer (Toco), which she places on the
abdomen, she states that this monitoring device provides an accurate evaluation of which of
the following?
a. Uterine hypertonus
b. Frequency of contractions
c. Intensity of contractions
d. Progress of labor

ANS: b
Feedback
a. Uterine tone is palpated or measured with an intrauterine pressure catheter (IUPC).
b. A tocotransducer measures frequency and duration of uterine contractions.
c. Contraction strength is palpated or measured with an intrauterine pressure catheter (IUPC).
d. Progress of labor is evaluated with a sterile vaginal examination (SVE).
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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Basic Care and Comfort | Difficulty Level: Easy

4. Early decelerations are probably caused by:

a. Decreased maternal–fetal exchange
b. Umbilical cord occlusion
c. Momentary increase in intracranial pressure due to head
compression d. Compression of umbilical cord

ANS: c
Feedback
a. Decreased maternal–fetal exchange results in late decelerations.
b. Umbilical cord occlusion results in variable deceleration or bradycardia.
c. Early decelerations are related to increased intracranial pressure due to head compression.
d. Compression of the umbilical cord results in variable decelerations.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

5. Which statement correctly describes the nurse’s responsibility related to electronic fetal
monitoring?
a. Teach the woman and her family about the monitoring equipment and discuss any questions
they have.
b. Report abnormal findings to the care provider before initiating corrective actions.
c. Inform the support person that the nurse will be responsible for all comfort measures when
the electronic equipment is in place.
d. Document the frequency, duration, and intensity of contractions measured by the external device.

ANS: a
Feedback
a. Teaching is an essential part of the nurse’s role.
b. Corrective measures for a non-reassuring fetal heart rate are done before notifying a provider.
c. The support person can help to provide comfort measures for women in labor.
d. Only an IUPC will measure the intensity of uterine contractions.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Comprehension | Content Area:
Maternity | Client Need: Basic Care and Comfort | Difficulty Level: Difficult

6. The nurse is caring for a woman, G2 P1001, 40 weeks’ gestation, in labor.

A 12 P.M. assessment revealed: cervix 4 cm, 80% effaced, –3 station, and fetal heart 124 with
moderate variability.
5 p.m. assessment: cervix 6 cm, 90% effaced, –3 station, and fetal heart 120 with minimal variability.
10 a.m. assessment: cervix 8 cm, 100% effaced, –3 station, and fetal heart 124 with absent
variability.
Based on the assessments, which of the following should the nurse conclude?
a. Descent is progressing well.
b. Woman is carrying a small-for-gestational age fetus.
c. Baby is potentially acidotic.
d. Woman should begin to push with the next contraction.

ANS: c
Feedback
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a. The baby has not descended since admission. The station is still –3.
b. The baby may be macrosomic. Because the baby is not descending, the baby may be too large to
traverse through the pelvis.
c. The variability is decreasing. This is an indication that the fetus is in distress.
d. The woman is only 8 cm dilated. She should not begin to push until she has reached 10 cm
dilation. Plus, the fetal station is still –3.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area:
Intrapartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health
Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level:
Difficult

7. After assessing the FHR tracing shown below, which of the following interventions should
the nurse perform?

a. Turn the woman on her side.

b. Administer oxygen by nasal cannula.
c. Encourage the patient to push with each contraction.
d. Provide the patient with caring labor support.

ANS: a
Feedback
a. The woman’s position should be changed. The side-lying position is the best.
b. If a laboring patient needs oxygen, it should be administered via face mask.
c. There is no indication in the scenario that the patient is fully dilated.
d. The nurse should not wait to intervene. He or she should intervene as quickly as possible in
order to reverse the problem.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content
Area: Intrapartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems |
Client Need: Health Promotion and Maintenance: Intrapartum Care; Physiological Integrity:
Reduction of Risk Potential | Difficulty Level: Moderate

8. A nurse is preparing to monitor a patient who is to receive an amnioinfusion. Which of

the following actions should the nurse make at this time?
a. Attach the patient to an electronic blood pressure cuff.
b. Assist in insertion of an internal uterine pressure catheter.
c. Attach the patient to an oxygen saturation monitor.
d. Perform an amniotic fluid Nitrazine test.

ANS: b
Feedback
a. The patient’s blood pressure will need to be monitored, but a manual cuff is sufficient.
b. There is a possibility of uterine rupture during an amnioinfusion. An internal pressure transducer,
therefore, must be inserted to monitor the patient’s intrauterine pressures.
c. The woman’s oxygen saturation levels need not be monitored during the amnioinfusion.
d. Because the woman’s membranes are already ruptured, there is no need for a Nitrazine test to be
performed.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content
Area: Intrapartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate
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9. The perinatal nurse providing care to a laboring woman recognizes a category II, fetal heart rate
tracing. The most appropriate initial action is to:
a. Assist the laboring woman to a left lateral
position b. Decrease the intravenous solution
c. Request that the physician/certified nurse-midwife come to the hospital
STAT d. Document the fetal heart rate and variability

ANS: a
Feedback
a. Because Category II fetal heart rate patterns could deteriorate, they constitute a risk indicator for
fetal hypoxia, the nurse should change the woman’s position to her side to increase oxygen flow to
the baby.
b. Because Category II fetal heart rate patterns could deteriorate, they constitute a risk indicator for
fetal hypoxia, the nurse should increase, not decrease, the IV infusion to increase perfusion through
the placenta.
c. The scenario described does not require STAT intervention but continued assessment after
intrauterine resuscitation interventions.
d. Documentation of the FHR is important but not the most important action in this scenario.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

Fill-in-the-Blank

10. The perinatal nurse assists the nursing student who is preparing the patient with
oligohydramnios for a fluid infusion into the uterine cavity. This procedure is described as a(n)
__________.

ANS: amnioinfusion
Pregnancy outcome in patients experiencing variable fetal heart rate decelerations caused by cord
compression is improved through the use of amnioinfusion, which is the instillation of normal
saline or lactated Ringer’s solution into the uterine cavity.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate