The nursing preceptor asks the nursing student how to determine the intensity of contractions before placing the client on the electronic fetal monitor. What is the best explanation?
Monitor the patient’s vocalizations and facial expressions.
Palpate the maternal abdomen during a contraction.
Time the amount of time between the ending of one contraction and the beginning of the next.
Palpate the maternal abdomen right after a contraction.
The Correct Answer is B
Choice A rationale
Monitoring the patient’s vocalizations and facial expressions can provide some information about the intensity of contractions, but it is subjective and not a reliable method for accurately assessing contraction intensity.
Choice B rationale
Palpating the maternal abdomen during a contraction is the best method for determining the intensity of contractions. By feeling the firmness of the uterus, the nurse can assess whether the contractions are mild, moderate, or strong. This method provides a more objective measure of contraction intensity compared to other methods.
Choice C rationale
Timing the amount of time between the ending of one contraction and the beginning of the next provides information about the frequency of contractions, not their intensity. This choice does not address the question of how to determine contraction intensity.
Choice D rationale
Palpating the maternal abdomen right after a contraction does not provide information about the intensity of the contraction that just occurred. The uterus will be relaxed after the contraction, making it difficult to assess the strength of the previous contraction.
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View Related questions
Correct Answer is A
Explanation
Choice A rationale
The “Passenger” refers to the fetus and its position, size, and presentation. In this case, the fetus has an estimated weight of 9 lbs and is in the left occiput posterior (LOP) position. These factors can complicate labor by making it more difficult for the fetus to navigate through the birth canal, potentially leading to prolonged labor and increased risk of interventions.
Choice B rationale
The “Passage” refers to the birth canal, including the pelvis and soft tissues. While the passage is an important factor in labor, the primary concern in this scenario is the size and position of the fetus, which falls under the “Passenger” category.
Choice C rationale
The “Powers” refer to the strength and frequency of uterine contractions. Although the patient is having contractions every 3 minutes, the main concern here is the fetal size and position, which are more directly related to the "Passenger"4.
Choice D rationale
The “Psyche” refers to the psychological state of the mother, including her stress levels and emotional well-being. While important, the primary concern in this scenario is the physical factors related to the fetus, which are categorized under the "Passenger"4.
Correct Answer is A
Explanation
Choice A rationale
A reactive non-stress test (NST) indicates that the fetal heart rate increases appropriately with fetal movements, suggesting good fetal oxygenation and neurological function. This is the desired outcome for an NST4.
Choice B rationale
A non-reactive NST means the fetal heart rate did not increase with movements, which could indicate fetal hypoxia or other issues. Further testing would be needed to assess fetal well-being.
Choice C rationale
An inconclusive NST means the test did not provide enough information to determine fetal well-being, possibly due to fetal sleep cycles or maternal factors. Additional testing would be required.
Choice D rationale
A positive NST is not a standard term used in fetal monitoring. The correct terms are reactive or non-reactive.