Chapter 15 Fetal Assessment during labor

The frequency of the contractions seen on the monitor tracing below is _____?

3 minutes

The duration of the contractions seen on the monitor tracing below is ?

90 seconds

The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination. In which of the following positions should the client be placed? 1. Orthopneic. 2. Lateral-recumbent. 3. Sims'. 4. Semi-Fowler's.

The client should be placed in a semi- Fowler's position. Rational: Because of the growth of the uterus, it is very difficult for women in the third trimester to breathe in the supine position. During the prenatal visit, the baby's heartbeat will be monitored, and the fundal height will be assessed. Both of these procedures can safely be performed in the semi-Fowler's position.

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary health care practitioner, which of the following assessments should the nurse perform? Select all that apply. a. Fetal heart rate. b. Contraction pattern. c. Urinalysis. d. Vital signs. e. Biophysical profile.

a. Fetal heart rate. b. Contraction pattern. d. Vital signs. Rational: The nurse should assess the fetal heart before reporting the client's status to the health care provider. The nurse should assess the contraction pattern before reporting the client's status. The nurse should assess the woman's vi- tal signs before reporting her status.

The nurse is interpreting the fetal monitor tracing below. Which of the following actions should the nurse take at this time? a. Provide caring labor support. b. Administer oxygen via tight-fitting face mask. c. Turn the woman on her side. d. Apply the oxygen saturation electrode to the mother.

a. Provide caring labor support. Rational: Because the variability is moderate (6 to 25 bpm wide), the nurse can conclude that the baby is well and that caring labor support is indicated.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? a. Provide caring labor support. b. Administer oxygen via face mask. c. Change the client's position. d. Speed up the client's intravenous.

a. Provide caring labor support. Rational: The tracing is showing a normal fetal heart tracing. No intervention is needed.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? a. The relationship between the decelerations and the labor contractions. b. The maternal blood pressure. c. The gestational age of the fetus. d. The placement of the fetal heart electrode in relation to the fetal position.

a. The relationship between the decelerations and the labor contractions. Rational: The relationship between the decelera- tions and the contractions will deter- mine the type of deceleration pattern.

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full- term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? a. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions. b. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. c. Baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. d. Baseline of 140 to 142 with no obvious decelerations or accelerations.

b. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. Rational: b. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions.

The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? a. Spontaneous fetal movement. b. Fetal heart acceleration. c. Increase in fetal heart variability. d. Resolution of late decelerations.

b. Fetal heart acceleration. Rational: The fetal heart should accelerate in response to scalp stimulation.

The nurse wishes to assess the variability of the fetal heart rate. Which of the follow-ing actions is recommended prior to performing this assessment? a. Place the client in the lateral recumbent position. b. Insert an internal fetal monitor electrode. c. Administer oxygen to the mother via face mask. d. Ask the mother to indicate when she feels fetal movement.

b. Insert an internal fetal monitor electrode. Rational: Before the variability can be accurately assessed, an internal fetal heart elec- trode should be applied.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? a. The client had poor childbirth education prior to labor. b. The client is exhibiting an expected behavior for labor. c. The client is becoming hypoxic and hypercapnic. d. The client needs her alpha-fetoprotein levels checked.

b. The client is exhibiting an expected behavior for labor. Rational: The woman is showing expected signs of the active phase of labor.

When would the nurse expect to see the monitor tracing shown below? a. During latent phase of labor. b. During an epidural insertion. c. During second stage of labor. d. During delivery of the placenta.

c. During second stage of labor. Rational: During second stage of labor.

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? a. The fetal position is transverse. b. The fetal presentation is vertex. c. The fetal lie is vertical. d. The fetal attitude is flexed.

c. The fetal lie is vertical. Rational: With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical.

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? a. After every contraction. b. For 10 minutes every half hour. c. Periodically during the peak of contractions. d. For 1 minute immediately after contractions.

d. For 1 minute immediately after contractions. Rational: Intermittent auscultation should be performed for 1 full minute after contractions end. 1. The frequency of intermittent auscultation is determined by which stage of labor the woman is in, not by contraction pattern. 2. The frequency of intermittent auscultation is determined by which stage of labor the woman is in. 3. Intermittent auscultation is performed between contractions, not during the peak of a contraction.

Which of the following frequency and duration assessments are consistent with the pattern shown below? a. q 2 min × 60 sec. b. q 2 min × 90 sec. c. q 3 min × 60 sec. d. q 3 min × 90 sec.

d. The contraction pattern is q 3 min × 90 sec

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? a. The fetus is becoming hypoxic. b. The fetus is becoming alkalotic. c. The fetus is in the middle of a sleep cycle. d. The fetus has a healthy nervous system.

d. The fetus has a healthy nervous system. Rational: Moderate variability is indicative of fetal health.