Ch. 15 - Fetal Assessment during Labor

The nurse caring for the laboring woman should understand that early decelerations are caused by:

Altered fetal cerebral blood flow. Early decelerations are the fetus's response to fetal head compression. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal heart rate unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations or loss of variability is nonreassuring and is associated with:

Hypoxemia. Nonreassuring heart rate patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Fetal variable decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.

What is an advantage of external electronic fetal monitoring?

The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor. The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor, particularly when the membranes are intact.

Fetal well-being during labor is assessed by

the response of the fetal heart rate (FHR) to uterine contractions (UCs). Fetal well-being during labor can be 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

A new client and her partner arrive on the labor, delivery, recovery, and postpartum unit for the birth of their first child. You apply the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby's heart rate should be. Your best response is:

"The top line graphs the baby's heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor." "The top line graphs the baby's heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor" educates the partner about fetal monitoring and provides support and information to alleviate his fears.

A tiered system of categorizing FHR has been recommended by regulatory agencies. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. These categories include (Select all that apply):

- Category I - Catergory II - Category III

Fetal well-being in labor can be measured by the response of the FHR to uterine contractions. Please match the characteristic of normal uterine activity during labor with the correct description.

- Frequency= Generally ranging from two to five contractions per 10 minutes of labor - Duration = Remaining fairly stable throughout the first and second stages - Strength = Peaking at 40 to 70 mmHg in the first stage of labor - Resting tone = Average of 10 mmHg - Relaxation time = Commonly 45 seconds or more in the second stage of labor

The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration (Select all that apply)?

- Placental abruption - Maternal supine hypotension

During labor a fetus with an average heart rate of 135 beats/min over a 10-minute period would be considered to have:

A normal baseline heart rate. The baseline heart rate is measured over 10 minutes; a normal range is 110 to 160 beats/min.Bradycardia is a fetal heart rate (FHR) below 110 beats/min for 10 minutes or longer. Tachycardia is an FHR over 160 beats/min for 10 minutes or longer.

The nurse providing care for the laboring woman comprehends that accelerations with fetal movement:

Are reassuring. Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.

According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR):

Before and after ambulation and rupture of membranes. The FHR should be auscultated before and after administration of medications and induction of anesthesia.

When assessing the relative advantages and disadvantages of internal and external electronic fetal monitoring, nurses comprehend that both:

Can be used during the antepartum and intrapartum periods. External monitoring can be used in both periods; internal monitoring can be used only in the intrapartum period. For internal monitoring the membranes must have ruptured, and the cervix must be sufficiently dilated.

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:

Change in position. Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position.

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to:

Change the woman's position. Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava.

A normal uterine activity pattern in labor is characterized by:

Contractions every 2 to 5 minutes. Contractions normally occur every 2 to 5 minutes and last less than 90 seconds (intensity 800 mm Hg) with about 30 seconds in between (20 mm Hg or less).

Perinatal nurses are legally responsible for:

Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes. Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions.

While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:

Document the finding in the client's record. The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings.

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:

Document the findings because they reflect the expected contraction pattern for the active phase of labor. The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse would document these findings in the client's medical record.

Which deceleration of the fetal heart rate would not require the nurse to change the maternal position?

Early decelerations Early decelerations (and accelerations) generally do not need any nursing intervention.

In assisting with the two factors that have an effect on fetal status (i.e., pushing and positioning), nurses should:

Encourage the woman's cooperation in avoiding the supine position. The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. The Valsalva maneuver, which encourages the woman to hold her breath and tighten her abdominal muscles, should be avoided.

Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by:

Expanding maternal blood volume. Filling the mother's vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most intravenous fluids for laboring women are isotonic and do not provide extra glucose.

The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is:

Fetal sleep cycles. A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes.

Which fetal heart rate (FHR) finding would concern the nurse during labor?

Late decelerations Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected.

What correctly matches the type of deceleration with its likely cause?

Late deceleration—uteroplacental inefficiency Late deceleration is caused by uteroplacental inefficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate may be caused by:

Methamphetamines. Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; methamphetamines may cause increased variability.

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?

Notify the care provider immediately. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately.

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take?

Notify the primary health care provider immediately (HCP) This 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.

The nurse knows that proper placement of the tocotransducer for electronic fetal monitoring is located:

Over the uterine fundus. The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use.

Fetal bradycardia is most common during

Prolonged umbilical cord compression. Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension

What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken.

Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. Repositioning the mother, increasing intravenous (IV) fluid, and providing oxygen via face mask are correct nursing actions for intrauterine resuscitation. The nurse should initiate intrauterine resuscitation in an ABC manner, similar to basic life support.

When using intermittent auscultation (IA) to assess uterine activity, the nurse should be cognizant that:

The examiner's hand should be placed over the fundus before, during, and after contractions. The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed.

Fetal well-being during labor is assessed by:

The response of the fetal heart rate (FHR) to uterine contractions (UCs). Fetal well-being during labor can be 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.

A nurse may be called on to stimulate the fetal scalp:

To elicit an acceleration in the fetal heart rate (FHR). The scalp can be stimulated using digital pressure during a vaginal examination. Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse would stimulate the fetal scalp to elicit an acceleration of the FHR.

When using intermittent auscultation (IA) for fetal heart rate, nurses should be aware that:

Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor. Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if ultrasound is used to help locate the heartbeat.

The nurse providing care for the laboring woman realizes that variable fetal heart rate (FHR) decelerations are caused by:

Umbilical cord compression. Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord.

Which maternal condition is considered a contraindication for the application of internal monitoring devices?

Unruptured membranes In order to apply internal monitoring devices, the membranes must be ruptured.

The nurse caring for a woman in labor understands that prolonged decelerations:

Usually are isolated events that end spontaneously. Prolonged decelerations usually are isolated events that end spontaneously. However, in certain combinations with late and/or variable decelerations, they are a danger sign that requires the nurse to notify the physician or midwife immediately. A deceleration that lasts longer than 10 minutes constitutes a baseline change.

Why is continuous electronic fetal monitoring usually used when oxytocin is administered?

Uteroplacental exchange may be compromised. The uterus may contract more firmly, and the resting tone may be increased with oxytocin use. This response reduces entrance of freshly oxygenated maternal blood into the intervillous spaces, thus depleting fetal oxygen reserves

The nurse caring for the woman in labor should understand that maternal hypotension can result in:

Uteroplacental insufficiency. Low maternal blood pressure reduces placental blood flow during uterine contractions and results in fetal hypoxemia. Maternal hypotension is not associated with early decelerations, fetal dysrhythmias, or spontaneous rupture of membranes.

The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are the result of:

Uteroplacental insufficiency. Uteroplacental insufficiency would result in late decelerations in the FHR.

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?

Variability averages between 6 to 10 beats/min. FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system

The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat

Variable decelerations. Amnioinfusion is used during labor either to dilute meconium-stained amniotic fluid or to supplement the amount of amniotic fluid to reduce the severity of variable decelerations caused by cord compression.

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by

change in position Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position

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. The nurse should:

describe the finding in the nurse's notes An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to:

initiation of epidural anesthesia that resulted in 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.

A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by

methamphetamines Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates may also result in a significant decrease in variability as these are known to cross the placental barrier. The use of illicit drugs, such as cocaine or methamphetamines, might cause increased variability

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to:

stop the Pitocin Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:

the examiner's hand should be placed over the fundus before, during, and after contractions The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. 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.