Chapter 15 - Fetal Assessment During Labor (Maternity) EAQ's
The primary health care provider has administered general anesthesia to a patient who is scheduled for an elective cesarean section. What changes should the nurse observe in the fetal heart rate (FHR) after the administration of general anesthesia? 1 Decrease 2 Increase 3 Minimal variability 4 Moderate variability
3 - Minimal variability pg 366 - It is necessary to monitor the FHR in the pregnant patient who is given general anesthesia. General anesthesia usually causes minimal variability or no change in the FHR. Tachycardia is caused by fetal hypoxemia, whereas bradycardia is caused from a structural defect in the fetal heart. Moderate variability in the FHR indicates normal fetal activity.
The primary health care provider has administered terbutaline (Brethine) to a pregnant patient to postpone preterm labor. What changes would the nurse observe in the fetal heart monitor after this drug was administered? 1 Increase in fetal heart rate 2 Decrease in fetal heart rate 3 Accelerations in heart rate 4 Decelerations in heart rate
1 - Increase in fetal heart rate pg 366 - Terbutaline (Brethine) is usually prescribed to postpone labor, because the drug reduces the frequency of uterine contractions. Terbutaline (Brethine) can also increase the fetal heart rate (FHR). Terbutaline (Brethine) does not decrease the heart rate, nor does it cause any accelerations or decelerations in the FHR. Heart block or viral infections can decrease the FHR and may result in bradycardia. There may be accelerations in the FHR during a vaginal examination. A parasympathetic response may cause decelerations in heart rate. Terbutaline is a sympathomimetic drug and thus does not cause decelerations in FHR.
Fetal well-being during labor is assessed by what? 1 The response of the fetal heart rate (FHR) to uterine contractions (UCs) 2 Maternal pain control 3 Accelerations in the FHR 4 An FHR greater than 110 beats/min
1 - The response of the fetal heart rate (FHR) to uterine contractions (UCs) pg 359 - Fetal well-being during labor is measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.
While monitoring the fetal heart rate (FHR), the nurse instructs the patient to change positions and lie in the knee-to-chest position. What is the reason for the nurse to give this instruction to the patient? 1 Late decelerations in the FHR 2 Variable decelerations in the FHR 3 Early decelerations in the FHR 4 Prolonged decelerations in the FHR
2 - Variable decelerations in the FHR pg 371 - Variable decelerations in the FHR are usually caused by umbilical cord compression. The knee-to-chest position is useful for relieving cord compression, and thus the nurse should ask the patient to move into this position. Prolonged decelerations in the FHR are not affected by the mother's position. If the nurse finds late decelerations in the FHR, the nurse should ask the mother to lie in the lateral position. Early decelerations in the FHR are a normal finding, and no nursing intervention is required.
The nurse is instructed to count the fetal heart rate (FHR) for 30 to 60 seconds after each uterine contraction in a pregnant patient via intermittent auscultation. This assessment helps to identify a change in what? 1 Placental flow 2 Fetal position 3 Baseline heart rate 4 Uterine activity
3 - Baseline heart rate pg 366 - Counting the FHR for 30 to 60 seconds after a uterine contraction (UC) helps to identify the baseline heart rate of the fetus and determine any changes in the pattern of the FHR. Palpating the abdomen will help identify the fetal position. Neither uterine activity (UA) nor placental flow can be identified by assessing the FHR after each UC. UA can be assessed by various methods, such as electronic fetal monitoring and external monitoring. A Doppler flow study under ultrasound visualization is mostly used to assess the placental flow from mother to fetus.
What should be the first step taken by the nurse when assessing fetal heart activity using an ultrasound transducer? 1 Auscultate the apical heart rate of the pregnant patient. 2 Apply some conductive gel on the maternal abdomen. 3 Apply some conductive gel on the ultrasound transducer. 4 Locate the maximal intensity area of the fetal heart rate.
4 - Locate the maximal intensity area of the fetal heart rate. pg 362 - Before the ultrasonic recording, the nurse should first locate the site on the abdomen where the maximal intensity of the fetal heart rate can be assessed. This should be done to find where the ultrasound transducer head can be placed. The apical heart rate of the patient need not be assessed before this procedure, because this procedure does not interfere with the cardiac activity of the pregnant patient. After finding the site of application, the nurse can apply conductive gel on the transducer and on the abdomen of the patient.
When the nurse observes this fetal heart pattern, what is the most important nursing action? 1 To document the finding 2 To position mother on left side 3 To apply 10 L of oxygen via face mask 4 To notify the health care provider
1 - To document the finding pg 369 - The fetal heart strip shows an early deceleration indicating expected head compression during contractions. Documenting this finding is appropriate. Positioning the woman on the left side, applying oxygen via a face mask, and notifying the health care provider are correct actions for a late deceleration.
After observing the fetal heart activity in the electronic fetal monitor, the nurse suspects that the patient's umbilical cord is compressed. What did the nurse observe on the monitor? 1 Fetal heart rate (FHR) variable decelerations 2 Increase in the FHR 3 Decrease in the FHR 4 Early decelerations
1 - Fetal heart rate (FHR) variable decelerations pg 370 - A compressed umbilical cord, which can be determined by variable decelerations in the FHR, is commonly observed at the time of labor. Variable decelerations are seen as W- or U-shaped waves on the monitor. Umbilical cord compression does not affect the heart rate. Early decelerations in the FHR are observed when the head of the fetus is compressed.
While auscultating for fetal heart tones in a pregnant patient, the nurse observes that there is persistent fetal tachycardia. In which situation would this finding be considered as normal? 1 If the patient's body temperature has increased 2 If the tachycardia is caused by late deceleration 3 If the tachycardia is related to minimal variability 4 If the patient's uterine contractions (UCs) are elevated
1 - If the patient's body temperature has increased pg 366 - Accelerations in the fetal heart rate (FHR) are usually episodic, and sometimes they may be persistent. When the patient is febrile, fetal tachycardia is not considered a serious event. The tachycardia would resolve once the patient is afebrile. Elevation in uterine contractions may cause episodic tachycardia, but it would not cause persistent tachycardia. Persistent tachycardia when associated with late deceleration or minimal variability is considered a risk to the fetus.
On assessment, the nurse notices that the fetal heart rate (FHR) is 100 beats/min. What could be a possible cause for this condition? 1 Maternal hypoglycemia 2 Chorioamnionitis 3 Low fetal oxygen supply 4 Decreased fetal hemoglobin levels
1 - Maternal hypoglycemia pg 366 - An FHR of less than 110 beats/min is referred to as bradycardia. Maternal hypoglycemia is a common cause of bradycardia in the fetus. Chorioamnionitis is an infection that also causes tachycardia in the fetus. Hypoxemia and anemia (decreased hemoglobin) of the fetus cause tachycardia in which the heart rate is more than 160 beats/min.
What category of fetal heart rate (FHR) tracing includes tachycardia with minimal variability and periodic variable decelerations? 1 Category I 2 Category II 3 Category III 4 Category IV
2 - Category II pg 360 - The tracing that contains tachycardia with minimal variability and periodic variable decelerations is a category II FHR tracing. A category II tracing is neither normal nor abnormal; it is indeterminate. A category I FHR tracing is normal (reassuring). A category FHR III is abnormal. Category IV does not exist.
The nurse is assessing the fetal heart rate (FHR) in a pregnant patient with diabetes during the first stage of labor. At what time intervals should the nurse perform FHR tracing? 1 5 minutes 2 60 minutes 3 15 minutes 4 30 minutes
3 - 15 minutes pg 372 - Diabetes is one of the risk factors in pregnancy. If any risk factors are present, the FHR tracing should be evaluated more frequently (every 15 minutes) in the first stage of labor and every 5 minutes in the second stage of labor. FHR should not be evaluated every hour in either low-risk or high-risk patients. In low-risk patients the FHR tracing should be evaluated for every 30 minutes during the first stage of labor.
The nurse is assessing a pregnant patient during labor and reports the normal duration of the contraction period as 2 minutes, 15 seconds in a span of 10 minutes. What would be the number of contractions observed in this span of 10 minutes? Record your answer using a whole number._______
In a pregnant patient the normal range of uterine contractions (UCs) during labor are noted to be 2 to 5 in every 10 minutes. Each one contraction lasts from 45 to 80 seconds. Therefore, when the nurse reports the contraction period as 2 minutes, 15 seconds (135 seconds) in 10 minutes of time, the nurse should have observed 135 ÷ 45 = 3 contractions. pg 360
After monitoring the fetal heart activity, the nurse documents the fetal heart rate (FHR) to be in category II, according to the three-tier FHR classification system. What findings would the nurse have observed? 1 Minimal variability 2 Moderate variability 3 Less than 110 beats/min 4 Presence of accelerations
1 - Minimal variability pg 360 - Minimum variability in the FHR indicates that there is insufficient oxygen supply to the fetus. This is categorized as a category II in a three-tier FHR classification system. Moderate variability in FHR indicates the normal cardiac activity of the fetus, which is categorized under category I. Bradycardia (FHR less than 110 beats/min) is categorized under category III. The FHR acceleration is completely absent according to category II and is present in category I.
While assessing a pregnant patient who is in labor, the nurse observes W-shaped waves on the fetal heart rate (FHR) monitor. What would the nurse infer from this observation? 1 Placental abruption 2 Dilated cervical layers 3 Umbilical cord compression 4 Elevated uterine contractions
3 - Umbilical cord compression pg 370/371 - W-shaped waves in the FHR monitor are indicative of variable decelerations in the FHR. Variable decelerations are seen when the umbilical cord is compressed at the time of labor. Placental abruption and dilated cervical layers do not cause variable decelerations but may cause late decelerations. Similarly, increased rate of uterine contractions may also cause late decelerations in FHR.
The nurse is teaching a group of nursing students regarding fetal oxygenation. The nurse questions a student, "What happens when oxytocin levels are elevated in the patient?" What would be the most appropriate answer given by the nursing student related to the patient's condition? 1 "Hemoglobin levels will decrease." 2 "Blood glucose levels will increase." 3 "Placenta lowers the blood supply." 4 "Uterine contractions (UCs) will increase."
4 - "Uterine contractions (UCs) will increase." pg 359 - An elevated level of oxytocin increases UCs during labor. A reduced hemoglobin level leads to a decreased oxygen supply to the fetus but is not a complication associated with an elevated oxytocin level. Oxytocin has no effect on the blood glucose levels. A family history of diabetes may increase the risk for gestational diabetes in the patient. Conditions such as hypertension in the patient may lower the blood supply to the placenta but are not associated with oxytocin levels.
The nurse has performed vibroacoustic stimulation and determines that the fetal heart rate (FHR) has increased by 15 beats/min from the baseline within 15 seconds. Which condition does this acceleration indicate? 1 Mixed acidemia in the fetus 2 Signs of respiratory acidemia 3 A normal pH level in the fetus 4 Elevated Pco2 level in the fetus
3 - A normal pH level in the fetus pg 373 - FHR acceleration by about 15 beats/min in 15 seconds on vibroacoustic stimulation indicates a normal blood pH of the fetus. A decreased pH and elevated carbon dioxide pressure indicate respiratory acidemia. Therefore FHR acceleration is not indicative of either respiratory acidemia or mixed acidemia in the fetus. The umbilical cord acid-base method involves the determination of both the carbon dioxide pressure and the oxygen pressure of the fetus.
While assessing a pregnant patient using a fetoscope, the nurse also palpates the abdomen of the patient. What is the purpose of palpating the abdomen of the patient? 1 Detection of fetal heart rate (FHR) deceleration 2 Evaluation of the severity of the pain caused by active labor 3 Assessment of pain from pressure applied by the fetoscope 4 Assessment of changes in FHR during and after contraction
4 - Assessment of changes in FHR during and after contraction pg 362 - While assessing the FHR with a fetoscope, the nurse palpates the abdomen of the fetus to evaluate uterine contractions (UCs). This is done to detect any changes in the FHR during and after UCs. FHR decelerations are not identified by palpating the abdomen. It is assessed using the electronic fetal monitoring system. Pain perception is a subjective assessment. Moreover, the pressure from the fetoscope is very minimal and does not cause pain.
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware of what? 1 The examiner's hand should be placed over the fundus before, during, and after contractions. 2 The frequency and duration of contractions are measured in seconds for consistency. 3 Contraction intensity is given a judgment number of 1 to 7 by the nurse and patient together. 4 The resting tone between contractions is described as either placid or turbulent.
1 - The examiner's hand should be placed over the fundus before, during, and after contractions. pg 360/362 - The assessment includes palpation: duration, frequency, intensity, and resting tone. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.
The nurse finds that the resting tone of the uterus of a pregnant patient is 30 mm Hg. Under which circumstance would this finding be considered normal? 1 When an amnioinfusion is administered to the patient 2 When oxytocin (Pitocin) has been given to the patient 3 When a blood sample is obtained from the fetal scalp 4 When the blood sample is tested for umbilical acid-base
1 - When an amnioinfusion is administered to the patient pg 374 - The average resting tone of the uterus is 10 mm Hg. When an amnioinfusion is done, the patient's uterine resting tone increases up to 40 mm Hg because of resistance to outflow of the fluid or turbulence of the catheter. Oxytocin (Pitocin) increases uterine activity (UA) but does not increase the resting tone of the uterus. Neither fetal scalp blood sampling nor umbilical cord blood sampling will have any effect on the resting tone of the uterus.
The nurse administers an amnioinfusion to a pregnant patient according to the primary health care provider's instructions. What is the reason behind the instructions? 1 Late decelerations 2 Early decelerations 3 Variable decelerations 4 Prolonged decelerations
3 - Variable decelerations pg 374 - Variable decelerations in the fetal heart rate (FHR) are observed when the umbilical cord is compressed. An amnioinfusion refers to the infusion of isotonic fluid into the uterine cavity when the amniotic fluid levels are decreased. This intervention is usually done for the prevention of umbilical cord compression. Late decelerations are observed when infections or elevated uterine contractions (UCs) are seen in a patient. This condition will be reversed by maintaining an IV solution, but aminoinfusion is not administered. Early deceleration in the FHR is a normal sign that does not require any intervention. Prolonged deceleration of the FHR occurs when there is a marked reduction of the fetal oxygen supply.
After reviewing the umbilical cord acid-base report, the nurse confirms that the fetus has respiratory acidosis. Which reading is consistent with the nurse's conclusion? 1 A base deficit value ≥12 mmol/L 2 Blood glucose levels = 120 mg/dL 3 Arterial pH >7.20 4 Partial pressure carbon dioxide >55 mm Hg
4 - Partial pressure carbon dioxide >55 mm Hg pg 374 - If Pco2 >55 mm Hg (elevated) and base deficit value <12 mmol/L and pH is <7.20, it indicates respiratory acidosis. In this case, the partial pressure carbon dioxide >55 mm Hg is indicative of respiratory acidosis. A pH >7.20 and base deficit value ≥12 mmol/L are all considered normal. Blood glucose level is not a part of this acid-base report.
The nurse is assisting a pregnant patient in labor. What instructions should the nurse give to the patient to promote comfort? Select all that apply. 1 "You should cough frequently." 2 "Breathe with your mouth open." 3 "Lie down in the lateral position." 4 "Lie in the supine position in bed." 5 "Lie in the semi-Fowler position."
2 - "Breathe with your mouth open." 3 - "Lie down in the lateral position." 5 - "Lie in the semi-Fowler position." pg 374 - The nurse helps the pregnant patient during labor. This includes teaching the patient relaxation techniques. The nurse teaches the patient to keep the mouth open during exhalation to allow air to easily leave the lungs. Placing the patient in a semi-Fowler or lateral position is helpful during labor. Therefore the nurse should instruct the patient to maintain a lateral or semi-Fowler position with a lateral tilt. Asking the patient to cough frequently would increase intraabdominal pressure of the patient and would make the patient uncomfortable. Having the patient lie down in a supine position during labor may cause orthostatic hypotension. Therefore the nurse should instruct the patient to lie down in a position other than supine.
The primary health care provider has asked the nurse to draw blood for an umbilical cord acid-base determination test. What should the nurse do in this situation? 1 Administer terbutaline (Brethine) before the test. 2 Collect blood from both the umbilical artery and vein. 3 First perform the fetal scalp stimulating technique. 4 Collect blood only from the baby's umbilical artery.
2 - Collect blood from both the umbilical artery and vein. pg 374 - An umbilical cord acid-base determination test is performed to assess the immediate condition of the neonate postpartum if there is an abnormal or confusing fetal heart rate (FHR) tracing found during labor. The nurse should collect blood from both umbilical artery and umbilical vein to perform the test. The fetal scalp stimulating technique is an indirect method to assess the fetal blood pH. This test need not be performed before the acid-base determination test. It is not necessary to administer terbutaline (Brethine), a uterine relaxant, before performing the test; it is administered during the time of labor if uterine contractions are too frequent.
When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110 beats/min. The rate of 110 beats/min persists for more than 10 minutes. The nurse can attribute this decrease in baseline to what? 1 Maternal hyperthyroidism 2 Initiation of epidural anesthesia that resulted in maternal hypotension 3 Maternal infection accompanied by fever 4 Alteration in maternal position from semirecumbent to lateral
2 - Initiation of epidural anesthesia that resulted in maternal hypotension pg 367 - Fetal bradycardia is the pattern described and results from the hypoxia that occurs when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. Hyperthyroidism would result in baseline tachycardia. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring FHR pattern.
Of these options, which is the nurse's priority action when observing this fetal heart pattern? 1 Notify the health care provider. 2 Assist with vaginal examination to assess for cord prolapse. 3 Change maternal position. 4 Assist with amnioinfusion.
3 - Change maternal position. pg 371 - The usual priority is as follows: (1) discontinue oxytocin if infusing; (2) change maternal position (side to side, knee chest); (3) administer oxygen at 8 to 10 L/min by nonrebreather face mask; (4) notify physician or nurse-midwife; (5) assist with vaginal or speculum examination to assess for cord prolapse; (6) assist with amnioinfusion if ordered; (7) assist with birth (vaginal-assisted or cesarean) if pattern cannot be corrected.
The nurse is caring for a pregnant patient during labor and documents the strength of uterine contractions (UCs) as "mild" after palpating the patient's abdomen. What reading of the intrauterine pressure catheter (IUPC) would be consistent with the strength of the UCs as assessed by the nurse? 1 40 mm Hg 2 60 mm Hg 3 80 mm Hg 4 100 mm Hg
1 - 40 mm Hg pg 374 - The UCs are assessed by palpating the patient's abdomen and reported as mild, moderate, or strong. The IUPC is an internal mode used to assess uterine activity (UA). The IUPC reading of less than 50 mm Hg is indicative of mild UCs. IUPC readings greater than 50 mm Hg are reported as moderate or strong after palpation.
The nurse is administering an amnioinfusion to a patient with oligohydramnios. What risk should the nurse primarily monitor for during administration? 1 Overdistention of the uterus 2 High risk for placental abruption 3 Fetal heart rate (FHR) accelerations 4 Increased uterine contractions (UCs)
1 - Overdistention of the uterus pg 374 - Oligohydramnios is the condition where the patient has low levels of amniotic fluid. In this condition the nurse should administer an amnioinfusion. During this process the nurse should assess the abdominal size to make sure the patient is not receiving too much fluid. This may cause overdistention of the uterus. This procedure does not affect the uterine activity (UA), placental hemorrhage, or the FHR. Placental abruption would cause conditions such as oligohydramnios. Decelerations in the FHR are observed in oligohydramnios, but accelerations are not.
The nurse caring for an active laboring patient reports to the health care provider that the fetal heart rate (FHR) tracing is reassuring and the Montevideo units are 60. What changes in the plan of care does the nurse anticipate from the health care provider? 1 Oxytocin augmentation 2 Placement of internal monitors 3 Artificial rupture of membranes 4 No changes in the plan of care
1 - Oxytocin augmentation pg 360 - The nurse can anticipate an order for oxytocin augmentation to increase the strength of the uterine contractions, which will be reflected in the increase of Montevideo units. Montevideo units of 60 are not reflective of an adequate labor pattern so the plan of care will be changed. Montevideo units can only be calculated with an internal monitor, which means the patient's membranes are already ruptured. The internal monitor that calculates Montevideo units is an intrauterine pressure catheter (IUPC); an internal fetal monitor is not necessary in this situation.
While assessing a pregnant patient, the nurse observes a sinusoidal heartbeat pattern on the electronic heart monitor. What should the nurse interpret about the fetus from this report? 1 Presence of fetal anemia 2 Mild hypoxemia 3 Metabolic acidemia 4 Potential for congenital anomalies
1 - Presence of fetal anemia pg 366 - A sinusoidal pattern of the fetal heart rate (FHR) is observed as a smooth wave-like pattern on the monitor. This indicates that the fetus has severe anemia. Minimal variability in the FHR indicates that the fetus may have mild hypoxemia and metabolic acidemia. Moderate variability in the FHR indicates that the fetus is at a risk of congenital anomalies.
What should the nurse assess while reviewing the umbilical cord acid-base report of a patient to determine placental function? 1 Umbilical vein report 2 Umbilical artery report 3 Amniotic fluid concentration 4 Blood glucose concentration
1 - Umbilical vein report pg 374 - The umbilical acid-base report helps determine the immediate condition of the newborn after birth. The nurse should check the umbilical vein report to determine the placental functioning of the patient. The placental function would help to assess the nutritional status of the newborn baby. The umbilical artery report is used to determine the physiologic functioning of the newborn. Amniotic fluid concentrations are monitored during labor, but not after birth. Blood glucose levels in the fetus are not assessed with the umbilical cord test.
The nurse observes late decelerations of the fetal heart rate (FHR) in the second phase of labor of a pregnant patient. The nurse assesses the pregnant patient and elevates the lower extremities of the patient. Which assessment finding would be the reason for this nursing intervention? 1 Placental abruption 2 Maternal hypotension 3 Maternal hemorrhage 4 Uterine contractions (UCs)
2 - Maternal hypotension pg 370 - Late decelerations in the FHR may be caused by maternal hypotension. Elevating the lower extremities helps control maternal hypotension and increase the blood flow to the uterus. Elevating the legs would not control hemorrhage, placental abruption, or UCs in a pregnant patient.
After observing the electronic fetal monitor, a primary health care provider asks the nurse to conduct an electrocardiogram (ECG) of the fetus. What should the nurse assess before obtaining an ECG of the fetus? Select all that apply. 1 Fetal lactate levels 2 Placental membranes 3 Cervical dilation 4 Umbilical cord compression 5 Frequency of uterine contractions
2 - Placental membranes 3 - Cervical dilation pg 363 - When performing the ECG of the fetus, the nurse should insert the electrode into the cervix to reach the fetus. Therefore the nurse should check if the cervix is dilated up to 3 cm and if the membranes are ruptured. This allows the nurse to reach the fetus's position. Lactate levels do not affect the ECG testing and thus need not be checked before the test. Umbilical cord compression and decreased frequency of UCs are not required conditions for performing an ECG on the fetus.
Fetal monitoring of a pregnant patient revealed that the fetal heart rate has minimal variability. Which prescribed drug is most likely responsible for the condition? 1 Hydroxyzine (Vistaril) 2 Terbutaline (Brethine) 3 Secobarbital (Seconal) 4 Atropine (Sal-Tropine)
3 - Secobarbital (Seconal) pg 366 - Variability in the fetal heart rate can be classified as absent, minimal, or moderate variability. This results in hypoxia and metabolic acidemia in the fetus. Central nervous system (CNS) depressants, such as secobarbital (Seconal), cause variability in the fetal heart rate. This medication affects the baseline heart rate in the fetus by less than 5 beats/min. Hydroxyzine (Vistaril), terbutaline (Brethine), and atropine (Sal-Tropine) may result in tachycardia in the fetus. These drugs can increase the baseline fetal heart rate as much as 25 beats/min.
The charge nurse instructed a group of student nurses about the monitoring of uterine activity (UA) during labor. Which statement by the student nurse is accurate regarding the calculation of Montevideo units? 1 "They can be calculated using an ultrasound transducer machine." 2 "They can be calculated using a spiral electrode monitoring device." 3 "They can be calculated using a tocotransducer monitoring system." 4 "They can be calculated with an intrauterine pressure catheter (IUPC)."
4 - "They can be calculated with an intrauterine pressure catheter (IUPC)." pg 360 - Montevideo units can only be calculated using the internal monitoring of UA. An intrauterine pressure catheter (IUPC) monitors UA internally. Therefore Montevideo units can only be calculated using the IUPC. Spiral electrode monitoring is used for assessing the fetal heart rate (FHR), not UA internally. The tocotransducer monitoring system is used to monitor the UA externally. An ultrasound transducer is also used to monitor the FHR externally
The primary health care provider prescribes terbutaline (Brethine) for a pregnant patient. As the nurse reviews the patient's medical record, what would be the rationale for this prescription? 1 Blood volume is elevated. 2 Hemoglobin is decreased. 3 Blood pressure is reduced. 4 Contractions are increased.
4 - Contractions are increased pg 373 - Terbutaline (Brethine) is administered to the patient who has premature labor. It slows down the contractions. Terbutaline (Brethine) has no effect on blood volume, blood pressure, or hemoglobin. Blood volume is elevated by infusing aggressive intravenous infusion or from sodium and water retention. Maternal hypotension, as evidenced by reduced blood pressure, is relieved by elevating the legs during labor. Patients with decreased hemoglobin are treated with iron supplements, not terbutaline (Brethine).
While performing a vaginal examination of the patient in active labor, the nurse notes decelerations in the fetal heart during uterine contractions (UCs). What should the nurse do in this situation? 1 Stop applying fundal pressure. 2 Discontinue the oxytocin (Pitocin) drip. 3 Change the maternal position. 4 Document it as a normal finding.
4 - Document it as a normal finding. pg 368 - Early decelerations in the FHR are common during UCs. These decelerations may also happen because of increased fundal pressure and during the placement of the internal mode of fetal monitoring. Applying fundal pressure during vaginal examination helps in accurate assessment; therefore fundal pressure needs to be applied. Oxytocin (Pitocin) administration induces UCs and indirectly causes the FHR to decelerate, but the medication should not be discontinued. The nurse would have the patient change positions if the umbilical cord was compressed.
When does the nurse use the fetal scalp stimulation technique to assess the fetal scalp pH? 1 If the patient's contractions have increased 2 If there is maternal weight loss in the last trimester 3 If fetal bradycardia is present 4 When the fetal heart rate (FHR) is within the baseline
4 - When the fetal heart rate (FHR) is within the baseline pg 373 - Fetal scalp and vibroacoustic stimulation are two stimulating methods that are used to determine the fetal scalp blood pH. They are performed only when the fetal baseline heart rate is within the normal range. These techniques are not suggested if there is fetal bradycardia. These stimulation methods are related to neither the patient's weight nor uterine contractions.
The nurse instructs a pregnant patient to breathe through the mouth and keep it open while pushing during labor. What is the rationale for this nursing intervention? 1 To avoid nasal congestion in the patient 2 To decrease the efforts required for pushing 3 To facilitate increased oxygen to the fetus 4 To avoid deceleration in the fetal heart rate
3 - To facilitate increased oxygen to the fetus pg 374 - During labor, the nurse asks the patient to breathe through the mouth to keep the mouth open to increase both maternal and fetal oxygenation. Nasal congestion is not a complication associated with labor. Opening of the mouth does not increase the pushing capability. Early decelerations are observed by pushing, which does not require any intervention.
The nurse assesses the fetal heart rate (FHR) of a pregnant patient and finds minimal FHR variability. The nurse reassesses the patient 30 minutes later and finds moderate variability. What should the nurse infer? 1 No acceleration 2 Late deceleration 3 Baseline heart rate is 150 beats/min 4 Baseline heart rate is 180 beats/min
3 - Baseline heart rate is 150 beats/min pg 366 - If the nurse notes minimal FHR variability, the nurse should reassess the heart rate to determine a pattern. If in 30 minutes the nurse notices moderate variability, the fetus may be in a sleep state. The nurse would further confirm after half an hour and report it as moderate variability, where the heart rate baseline is confirmed as normal (110-160 beats/min). Heart rate variability is a characteristic of the baseline FHR and does not include accelerations or decelerations of the FHR. A fetal baseline heart rate of 180 beats/min is considered severe variability.
The nurse is assessing a pregnant patient through a tocotransducer placed externally and a spiral electrode placed internally. What information would the nurse obtain by this arrangement? Select all that apply. 1 Lactate levels in the fetal blood 2 Strength of uterine contractions 3 Duration of uterine contractions 4 Frequency of uterine contractions 5 Accelerations of fetal heart rate
3 - Duration of uterine contractions 4 - Frequency of uterine contractions 5 - Accelerations of fetal heart rate pg 362 - A tocotransducer is an external device that is used for assessment of uterine activity (UA). This instrument would report duration and frequency of the uterine contractions (UCs). The spiral electrode can monitor accelerations of the fetal heart rate. These systems do not report the intensity of UCs. Strength of UCs can be assessed using an intrauterine pressure catheter (IUPC). Neither a tocotransducer nor a spiral electrode is used to determine the lactate level; it is obtained by the fetal scalp sampling method.
After monitoring the fetal heart activity, the nurse concludes that there is impaired fetal oxygenation. What had the nurse observed in the fetal monitor to come to this conclusion? Select all that apply. 1 Increase in the fetal heart rate (FHR) to over 160 beats/min 2 Early decelerations 3 Moderate variability 4 Late decelerations 5 Occasional variable decelerations
1 - Increase in the fetal heart rate (FHR) to over 160 beats/min 4 - Late decelerations pg 370 - Tachycardia (an increase in the FHR) is the early sign of fetal hypoxemia. Late decelerations are caused by a reflex fetal response to transient hypoxemia during a uterine contraction that reduces the delivery of oxygenated blood to the intervillous space of the placenta. Early decelerations, moderate variability, and occasional variable decelerations in the FHR are common observations during labor. These are normal findings and require no intervention.
The nurse is caring for a low-risk obstetrical patient in the latent phase of labor. The patient states, "I want to walk around without the fetal monitor on me." How will the labor nurse safely monitor the fetus? 1 Periodically obtain a heart rate and variability with a Doppler. 2 Periodically auscultate before, during, and between contractions. 3 Intermittently place the external fetal monitor to evaluate the fetal heart rate (FHR). 4 Intermittently auscultate before, during, and for at least 30 seconds after the contraction.
4 - Intermittently auscultate before, during, and for at least 30 seconds after the contraction. pg 360 - The nurse will intermittently auscultate before, during, and for at least 30 seconds after the contraction to assess for nonreassuring FHR findings such as an abnormal rate or baseline changes. The nurse is unable to assess variability with a Doppler, and in a laboring woman, fetal wellbeing is partly evaluated by assessing the fetal heart rate in response to uterine contractions. It is not necessary to place the external fetal monitor back on the patient to evaluate the FHR. The patient may be monitored by intermittent auscultation as long as no risk factors are present. The nurse must also auscultate the FHR before, during, and after, not between, the contractions to ensure there are no abnormal rate or baseline changes.
After administering phenylephrine (Neo-Synephrine) as prescribed to a pregnant patient, the nurse places three pillows under the patient's lower extremities. What is the rationale for this intervention? 1 To reduce the fetal heart rate 2 To reduce the effects of tachysystole 3 To prevent adverse effects of the drug 4 To increase the patient's blood pressure
4 - To increase the patient's blood pressure pg 370/373 - Phenylephrine (Neo-Synephrine) is used to treat maternal hypotension. Elevating the lower limbs would supplement the action of the drug and prevent the maternal hypotension from affecting the fetus. Tachysystole is reduced by administering terbutaline (Brethine), not by changing the position of the patient. The prescribed dose of phenylephrine (Neo-Synephrine) is unlikely to cause any adverse effects in the patient. Phenylephrine (Neo-Synephrine) has no effect on the fetal heart rate (FHR).
