Vsim Carla Hernandez Pre/Post-test
Baseline Fetal Heart Rate
120-160 BPM Preserved beat-to-beat and long-term variability
Deceleration
A brief period of bradycardia
Fetal Tachycardia
Above 160 BPM
Variability
Normal fluctuation of the fetal heart rate
Variable Decelerations
Variables in duration, intensity, and timing Acceleration-Deceleration-Acceleration is due to compression and decompression of the cord
During the initial assessment for Carla Hernandez, there was bradycardia, late decelerations, and minimal variability. The nurse could determine that measures to relieve umbilical cord compression were successful by which of the following evaluative findings?
long-term variability was 10 to 15 beats per minute The umbilical cord had a pulse The umbilical cord had a pH of 7.3 and maternal oxygen saturation was at 98%
Mnemonic for cord prolapse: CORD
*C* - Call for help *O* - Organize delivery *R* - Relieve pressure on the cord *D* -Deliver
A laboring woman called the nurse to report her bag of water broke and she feels a pulsation in her vagina. The nurse notes variable decelerations with fetal bradycardia on the fetal monitor and suspects prolapsed umbilical cord. Put into order he interventions the nurse should perform:
1) Call the charge nurse to notify the provider and prepare for immediate delivery 2) Insert a gloved hand into the vagina to relieve pressure on the umbilical cord 3) Assist the patient into the knee-chest position 4) Administer oxygen by non-rebreather mask at 10 L/min 5) Explain emergency measures and rationales to the patient and her support person 6) Ensure that there are no further abnormal fetal heart rate patterns 7) Document the actions and procedures taken to resolve this situation
Reactivity
A type of variability How much the heart rate responds to fetal rest or movements as well as to other stress
The nurse received report for Carla Hernandez before taking over her care. What was the most important piece of information communicated to the nurse that expedited care of this patient?
Amniotomy performed by provider to facilitate labor. Explanation: Performed amniotomy is a risk factor for umbilical cord prolapse
What is the most important action the nurse would take when a prolapsed cord has been identified?
Apply a sterile gloved hand in the vagina to lift the presenting part off of the cord to alleviate cord compression until delivery
The nurse takes measures to preserve the integrity of the visible umbilical cord prolapse to maintain blood flow to the fetus. Which of the following are appropriate measures?
Assess the exposed umbilical cord for color and pulsation Use a gloved hand to lift the presenting part of the cord Explanation: The nurse would try to reestablish blood flow to the fetus by placing a gloved hand into the vagina and lifting the presenting part off of the cord The exposed umbilical cord is not pushed back into the vagina, because this action could cause the umbilical vessels to be kinked and cut off the blood flow to the fetus
Fetal Bradycardia
Below 120 BPM
Carla Hernandez's fetal membranes were ruptured by her provider. Immediately following the procedure, the nurse notes persistent fetal bradycardia on the fetal monitor. This could indicate which of the following?
Compression of the umbilical cord
The labor and delivery nurse notices that a laboring woman's external fetal monitor shows a variable deceleration. what is the common etiology of this non-reassuring fetal periodic pattern?
Cord compression Explanation: Fetal variable decelerations are commonly associated with umbilical cord compression
As Carla Hernandez is taken back to the operating room for an emergent cesarean delivery, her husband expresses anxiety about his wife and his baby. What is the most therapeutic communication that the nurse can make?
Delivery is needed because the blood flow through the umbilical cord is not getting enough oxygen to the baby. I understand that you are concerned about the well-being of your wife and baby. What are you feeling?
he nurse is admistting a labor woman at 39 weeks gestation. Which of the following are risk factors for prolapsed umbilical cord (sata)
Estimated fetal weight of 2,400 g (5 lb, 1 oz) Amniotomy performed at station -2 Multiple gestation Amniotic fluid 2,200 mL Explanation: risk factors for an umbilical cord prolapse incude the following" Low birth weight, being second twins, transverse lie, breech presentation, preterm labor (less than 37 weeks), Poly hydramnios (greater than 2,000 mL), amniotomy (especially when fetus is not engaged), prematuer rupture of the membranes, placenta previa, and a long cord
Which of the following statements is true concerning prolapsed umbilical cord?
It is an emergency that requires immediate measures to minimize the fetal mortality or morbidity from hypoxia Explanation: The occurrence of the prolapsed umbilical cord is approximately 1 in 300-600 births, or 3% of the cephalic presentations and 3.7% of breech presentations. A prolapsed umbilical cord is an obstetric emergency that requires immediate attention to prevent acidosis from the fetal hypoxia.
Which of the following nursing diagnoses has the highest priority in the care of Carla Hernandez during an umbilical cord prolapse?
Impaired gas exchange in the fetus related to decreased blood perfusion
Severe Variable Decelerations
Indicated by a depth below 70 BPM, and a duration longer than 1 minute *Persistent variable decelerations may lead to acidosis and fetal distress*
Types of cord prolapse
Occult (hidden) prolapse Cord prolapse in front of fetal head Complete cord prolapse
A woman in active labor reports to the nurse that she thinks that her bag of waters has broken. What is the first assessment that the nurse performs at this time?
Monitor the fetal heart rate and pattern Explanation: When the fetal membranes rupture, then the presenting part can put pressure on the umbilical cord. the first assessment to make is the fetal heart rate and pattern to ensure the fetus is getting enough oxygen through the umbilical cord
To prepare for an immediate cesarean delivery for Carla Hernandez, what would the nurse do first?
Obtain an informed consent
The nurse is preparing for an emergency cesarean birth for a patient who has prolapsed cord visible at the vulva. Which interventions would the nurse take for this surgical procedure?
Obtain an informed consent from the patient or family member Review results for diagnostic tests, including CBC, ABO group, Rh compatibility, Urinalysis Administer the ordered preoperative intravenous medications Assess the intravenous site for patency and hang a full bag of IV fluids Explanation: This procedure is a surgical intervention. The proper steps need to be taken to ensure patient consent and safety.
Which of the following nursing measures has the highest priority when an intrapartum woman has a prolapsed umbilical cord?
Place sterile gloved hand into patient's vagina to push the fetus off the umbilical cord Explanation: The immediate concern is to reestablish blood flow through the umbilical cord. Why, the nurse would push the presenting part off the cord to relieve the compression. Position changes to relieve compression: knee-to-chest, trendelenburg, hips higher than chest, modified Sims
After the umbilical cord prolapse has been identified, which of the following personnel should the nurse inform of this emergency?
Provider Charge Nurse Surgery/OR Anesthesia NICU
Carla Hernandez was in active labor when the umbilical cord prolapse was identified. The provider ordered a tocolytic agent to relax the uterine smooth muscle. What is the best route for administering terbutaline sulfate to the patient in this situation?
Subcutaneous, back of arm at the side of the deltoid
What is the primary purpose for a provider order for terbutaline sulfate to be given to a laboring patient who presents with a prolapsed umbilical cord?
To relax the uterine smooth muscles to allow for improved fetal blood flow Explanation: This medication is being used as a tocolytic agent, which inhibits uterine contractions. The primary reason for its administration is to prevent smooth muscle contractions of the uterus to allow for an immediate C-section
Acceleration
Transient increase in the heart rate above the normal baseline in response to fetal activity, or a benign stress such as maternal excitement or exercise Accelerations last for 15 or more seconds above the baseline, and peak to 15 or more BPM
The nurse monitors for adverse effects from terbutaline sulfate, which was given to Carla Hernandez after umbilical cord prolapse was identified. Which of the following are signs of adverse effects of this drug?
maternal heart rate 154, regular maternal blood pressure 152/94 mm Hg auscultate crackles throughout the lungs
Complete cord prolapse
the cord can be seen protruding from the vagina
Cord Prolapse in front of the fetal head
the cord cannot be seen but can be felt as a pulsating mass during vaginal exam
Occult (hidden) Prolapse
the cord is compressed between the fetal presenting part and the pelvis, but cannot be seen or felt during vaginal exam
