Under which circumstance would it be unnecessary for the nurse to ...

[EAugust]

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination?
 
  a. An admission to the hospital at the start of labor
  b. When accelerations of the fetal heart rate (FHR) are noted
  c. On maternal perception of perineal pressure or the urge to bear down
  d. When membranes rupture

Question 2

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is:
 
  a. Usually directly over the fetal abdomen.
  b. In a vertex position heard above the mother's umbilicus.
  c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally.
  d. In a breech position heard below the mother's umbilicus.

[Christopher]

Answer to Question 1

ANS: B
An accelerated FHR is a positive sign; however, variable decelerations merit a vaginal examination. Vaginal examinations should be performed when the woman is admitted, when she perceives perineal pressure or the urge to bear down, when her membranes rupture, when a significant change in her uterine activity has occurred, or when variable decelerations of the FHR are noted.

Answer to Question 2

ANS: C
Nurses should be prepared for the shift. The PMI of the FHT usually is directly over the fetal back. In a vertex position it is heard below the mother's umbilicus. In a breech position it is heard above the mother's umbilicus.