NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the low-risk laboring client during the first stage of labor. When should the nurse assess the FHR pattern? Select all that apply.
Correct Answer: A,C
Rationale: The FHR may be affected by medications given to the mother.
Therefore, a baseline FHR should be determined before giving any medication to the laboring client and then assessed again after giving the medication. The FHR should be assessed after each vaginal examination because the fetus could change positions, or be stressed by the intrusion of the examiner’s fingers, or intact membranes could have ruptured. The FHR should be assessed every 30 minutes (not 15 minutes) during the first stage of labor if the client is categorized as low risk. The FHR should be assessed every 15 minutes during the second stage of labor. Although the FHR could be listened to during a contraction, it may be difficult due to muffling of the sounds and maternal movement. It is most important to listen before and after the contraction to more accurately detect FHR decelerations. If the client is classified as low risk, she should not be receiving oxytocin (Pitocin) for labor augmentation or induction.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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