Chapter 18, Fetal Assessment During Labor

Which device can be used as a noninvasive way to assess fetal heart rate (FHR) in the client whose membranes are not ruptured?

Ultrasound transducer

When monitoring the client in labor, the nurse knows that the likely cause of variable fetal heart rate (FHR) decelerations is which factor?

Umbilical cord compression

While assessing a pregnant client who is in labor, the nurse observes W-shaped waves on the fetal heart rate (FHR) monitor. Which situation would the nurse infer from this observation?

Umbilical cord compression

The nurse is monitoring the client's fetal heart rate (FHR) and notices late decelerations associated with uterine contractions, including a gradual decrease in and return to baseline. To which condition would the nurse attribute this pattern?

Uteroplacental insufficiency

Which assessment would the nurse make after assessing an electronic fetal heart tracing that indicates umbilical cord compression?

Variable decelerations

Which device would the nurse use for monitoring the intensity of uterine contractions in a pregnant client?

Intrauterine pressure catheter (IUPC)

The nurse is caring for a client with electronic fetal monitoring using a spiral electrode. How is the use of a spiral electrode different from the use of an ultrasound transducer?

It is used after the membranes have ruptured.

The nurse is teaching a group of student nurses about fetal oxygenation. The nurse asks a student, "What happens when oxytocin levels are elevated in the client?" Which statement by the student nurse indicates effective learning related to the client's condition?

"Uterine contractions will increase."

Which are characteristics of a uterine contraction? Select all that apply.

-Frequency (how often contractions occur) -Intensity (the strength of the contraction at its peak) -Resting tone (the tension in the uterine muscle between contractions)

At which interval during the first stage of labor would the nurse assess the fetal heart rate (FHR) tracing in a pregnant client with diabetes?

15 minutes

The nurse observes late decelerations in the fetal heart rate (FHR) in the second stage of labor. After assessing the client, the nurse elevates the lower extremities. Which assessment finding would be the reason for this nursing intervention?

Maternal hypotension

The nurse caring for a client in labor understands that the cause of increased variability in fetal heart rate might be which factor?

Methamphetamines

After assessing fetal heart activity, the nurse documents the fetal heart rate (FHR) to be in category II. According to the three-tier FHR classification system, which findings would indicate a category II FHR?

Minimal variability

When assessing the fetal heart rate (FHR) of a client in labor, which would the nurse identify as normal variability of the FHR?

Moderate variability

The nurse is administering an amnioinfusion to a client with oligohydramnios. Which risk would the nurse primarily monitor for during administration?

Overdistension of the uterus

While caring for a client receiving a nonstress test (NST), the nurse does not observe accelerations in fetal heart rate (FHR) after 30 minutes of FHR monitoring. Which intervention would the nurse perform to elicit FHR accelerations?

Provide vibroacoustic stimulation.

The nurse is monitoring the fetal heart rate (FHR) of a full-term client in labor. Which measure would the nurse take to obtain the most accurate baseline FHR?

Record or monitor a 10-minute segment of tracing.

The nurse assesses fetal well-being during labor by monitoring which factor?

Response of the fetal heart rate (FHR) to uterine contractions

The nurse observes late decelerations in the fetal heart rate (FHR) while caring for a client in labor. Which nursing intervention would the nurse perform first for this client?

Arrange for internal FHR monitoring.

While assessing a pregnant client using a fetoscope, the nurse also palpates the client's abdomen because of which factor?

Assessment of changes in fetal heart rate during and after contraction

Which laboring client would the nurse expect to be a likely candidate for amnioinfusion?

A client with heavily meconium-stained amniotic fluid or a low amniotic fluid index (AFI)

The nurse is monitoring the fetal heart rate (FHR) of a client in term labor. The FHR varies between 120 and 130 beats/min over a 10-minute period. How would the nurse record the baseline? Record your answer using a whole number. ________ beats/min

After 10 minutes of tracing is observed, the approximate mean rate is rounded to the closest 5 beats/min interval, which is 125 beats/min.

The nurse is using auscultation to determine fetal heart rate (FHR) during the first stage of labor. Which measures would the nurse use to reassure the client if it takes considerable time to locate and count the heartbeats?

Allow the client to listen to the heartbeat.

The nurse is assessing a pregnant client and using spiral electrode monitoring to record the fetal heart rate (FHR). Under which circumstances would the nurse consider implementing this method?

The cervix is partially dilated.

The nurse caring for a laboring client is aware that maternal cardiac output can be increased by which factor?

Change in position

The primary health care provider has asked the nurse to draw blood for an umbilical cord acid-base determination test. Which intervention would the nurse perform in this situation?

Collect blood from both the umbilical artery and umbilical vein.

The primary health care provider prescribes terbutaline for a pregnant client. After assessing the client's record, the nurse knows the rationale for this prescription should be which condition?

Contractions are increased.

When assessing uterine activity, the nurse is aware of which consideration?

The examiner's hand should be placed on the fundus before, during, and after contractions.

Which statement is accurate regarding episodic accelerations in fetal heart rate (FHR) with fetal movement when caring for a laboring client?

They are reassuring of fetal well-being.

Which statement by the nurse is accurate regarding the calculation of Montevideo units for monitoring uterine activity during labor?

They can be calculated with an intrauterine pressure catheter (IUPC).

While performing a vaginal examination for the client in active labor, the nurse notes early decelerations in the fetal heart rate (FHR) during uterine contractions. Which nursing intervention is appropriate in this situation?

Document it as a normal finding.

The nurse is helping a pregnant client during labor by applying fundal pressure. What alteration in the fetal heart rate (FHR) pattern would result from this intervention?

Early decelerations

Which fetal heart rate tracing characteristics are considered reassuring or normal (category I)?

Early decelerations, either present or absent

While monitoring the fetal heart rate (FHR) of a client in labor, the nurse notes tachycardia. Which is a probable cause for this condition?

Early signs of fetal distress

The nurse instructs a laboring client to breathe through the mouth and keep it open while pushing during the second stage of labor. Which is the rationale for this nursing intervention?

Facilitating increased oxygen to the fetus

While monitoring the fetal heart rate (FHR) of a pregnant client, the nurse notes a regular, smooth, undulating wavelike pattern. Which condition would the nurse suspect when observing this pattern?

Fetal anemia

Which location would the nurse utilize to assess and hear loud, clear fetal heart sounds?

Fetal back

The nurse is assessing the fetal heart rate (FHR) tracing for a client and determines an FHR baseline of 175 beats/min. The nurse knows that this can be caused by which factor?

Fetal tachycardia

The nurse is evaluating the fetal monitor tracing of a client who is in active labor and notes a sudden drop in fetal heart rate (FHR) from its baseline of 125 down to 80. The nurse repositions the client, provides oxygen, increases intravenous (IV) fluid, and performs a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. Which additional measure would the nurse take?

Immediately notify the primary health care provider.