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1. A 25-year-old primigravida at 39 weeks of gestation is
admitted to the labor and delivery unit with regular
contractions. Her cervix is 4 cm dilated and 80?faced.
The fetal heart rate (FHR) is 140 beats per minute with
moderate variability and no decelerations. The nurse
should:
a) Prepare for an imminent delivery
b) Administer oxytocin to augment labor
c) Monitor the FHR and uterine activity continuously
d) Perform a vaginal exam every hour to assess progress
*Answer: c) Monitor the FHR and uterine activity
continuously*
Rationale: The nurse should monitor the FHR and uterine
activity continuously to assess the well-being of the fetus
and the progress of labor. The FHR pattern is reassuring
and indicates adequate oxygenation. The cervix is not fully
dilated and there is no indication of fetal distress or
maternal complications that would require immediate
delivery or augmentation of labor. A vaginal exam every
hour is unnecessary and may increase the risk of infection.
2. A 32-year-old multipara at 41 weeks of gestation is
undergoing induction of labor with oxytocin. Her cervix is
6 cm dilated and 90?faced. The FHR is 150 beats per
minute with minimal variability and late decelerations. The
nurse should:
a) Increase the oxytocin infusion rate to hasten delivery
b) Decrease the oxytocin infusion rate and administerÂÂ
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