Chapter 15: Fetal Assessment During Labor
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 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.
Fetal monitoring of a pregnant patient revealed a regular smooth, undulating wavelike pattern of the fetal heart rate (FHR). What should the nurse infer about the fetus from these results? 1 Anemia 2 Ischemia 3 Hypertension 4 Hypotension
1 A regular smooth, undulating wavelike pattern in the FHR is referred to as a sinusoidal pattern. This uncommon pattern mostly occurs with severe fetal anemia. Ischemia refers to impaired circulation. FHR patterns cannot indicate this condition. Blood pressure levels below 120/80 mm Hg indicate hypotension. Blood pressure levels above 120/80 mm Hg indicate hypertension. The FHR pattern cannot indicate conditions such as hypotension or hypertension.
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 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 review of a fetal monitor tracing, the nurse notes that for several contractions the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. What should the nurse do? 1 Describe the finding in the nurse's notes. 2 Reposition the woman onto her side. 3 Call the physician for instructions. 4 Administer oxygen at 8 to 10 L/min with a tight face mask.
1 An early deceleration pattern from head compression is described. No action other than documentation of the finding is required because this is an expected reaction to compression of the fetal head as it passes through the cervix. Repositioning the woman onto her side would be implemented when nonreassuring or ominous changes are noted. Calling the physician would be implemented when non-reassuring or ominous changes are noted. Administering oxygen would be implemented when nonreassuring or ominous changes are noted.
The nurse is assessing a pregnant patient and uses spiral electrode monitoring to record the fetal heart rate. Under what circumstances can the nurse consider implementing this method? 1 The cervix has partially dilated. 2 Uterine contractions have increased. 3 The patient's placenta cannot be ruptured. 4 The umbilical cord is compressed.
1 Spiral electrode monitoring is used to determine the fetal heart rate during the intrapartum period. Because the spiral electrode is introduced into the cervix, the nurse needs to make sure that the patient's cervix is partially dilated. This allows the nurse to properly place the equipment to hear the heart sounds of the fetus. Ruptured placental membranes are also one of the considerations for using spiral electrode monitoring. A compressed umbilical cord and increased uterine contractions (UCs) are not factors that are considered for using a spiral electrode.
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 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.
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 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.
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 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.
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 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 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 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.
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 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 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 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.
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 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.
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 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.
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 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.
Which device should the nurse use for monitoring the intensity of uterine contractions (UCs) in a pregnant patient? 1 Tocotransducer 2 Spiral electrode 3 Ultrasound transducer 4 Intrauterine pressure catheter (IUPC)
4 An IUPC measures the frequency, duration, and intensity of contractions during the intrapartum period. The device records the pressure at the catheter tip, and the values are expressed in terms of mm Hg. However, for accurate readings, the membranes should be ruptured and the cervix should be dilated. A tocotransducer monitors the frequency and duration of contractions for both antepartum and intrapartum care. This device is placed on the abdomen of the patient. The spiral electrode and ultrasound transducer are used for assessing the fetal heart rate and not the intensity of contractions. The spiral electrode is an invasive mode, whereas an ultrasound transducer is a noninvasive mode.
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 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.
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 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.
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 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 evaluating the fetal monitor tracing of a patient who is in active labor. Suddenly, the fetal heart rate (FHR) drops from its baseline of 125 beats/min down to 80 beats/min. The nurse repositions the mother, provides oxygen, increases intravenous (IV) fluid, and performs a vaginal examination. The cervix has not changed. A few minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take? 1 Notify nursery nurse of imminent birth. 2 Insert a Foley catheter. 3 Start oxytocin (Pitocin). 4 Notify the primary health care provider (HCP) immediately.
4 If the FHR does not resolve, the primary HCP should be notified immediately. Notifying the nursery nurse that birth is imminent is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean birth may be warranted. This requires the insertion of a Foley catheter; however, the HCP must make that determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also, if oxytocin is infusing, it should be discontinued.
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 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 nurse observes variable decelerations in fetal heart rate (FHR) while assessing a pregnant patient with oligohydramnios. What medication should be immediately given to the patient? 1 Oxytocin (Pitocin) 2 Terbutaline (Brethine) 3 Phenylephrine (Endal) 4 Lactated Ringer's solution
4 Oligohydramnios is a condition that may cause umbilical cord compression and results in variable decelerations in the FHR. Usually lactated Ringer's or normal saline solution can be administered into the umbilical cord to increase the amniotic fluid volume and normalize fetal heart activity. Terbutaline (Brethine) is a uterine relaxant. It is mostly used to reduce uterine tachysystole. The nurse can administer phenylephrine (Endal) if other measures are unsuccessful in improving maternal hypotension. Oxytocin (Pitocin) is a uterine stimulant to induce labor. It is not used to reduce the umbilical cord compression.
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 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).
The nurse has a prescription to obtain a blood sample from a patient to determine fetal lactate levels. What information should the nurse provide to the patient before the procedure? 1 "There is an increased risk for after birth hemorrhage." 2 "There may be a need to reconduct the diagnostic test." 3 "There is an increased risk for requiring a cesarean birth." 4 "There will be a small incision on the scalp of the newborn."
4 The fetal blood is collected by making a small incision on the fetal scalp, which is visible in the newborn. This might be disturbing to the patient, but the nurse should help the patient understand the purpose of the test. Postpartum hemorrhage or increased risk for cesarean birth is not associated with this procedure. The test has to be conducted only once, and it does not have to be reconducted.