14: Intrapartum fetal surveillance

Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.) a. Oxytocin (Pitocin) b. Misoprostol (Cytotec) c. Dinoprostone (Cervidil) d. Methylergonovine maleate (Methergine)

ANS: A, B, C, D Oxytocin, misoprostol, and dinoprostone fall under the general category of uterine stimulants. Cytotec and Cervidil are prostaglandins. Methergine is an ergot alkaloid.

In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding? a. The fetus is at 30 weeks of gestation. b. The mother has a history of fast labors. c. The mother has been given an epidural block. d. The mother has mild preeclampsia but is not in labor.

ANS: A The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Fast labors should not alter the FHR normally. Any change in the FHR with an epidural is not considered an expected outcome. Preeclampsia should not cause a normal elevation of the FHR.

Which statement correctly describes the nurse's responsibility related to electronic monitoring? a. Report abnormal findings to the physician before initiating corrective actions. b. Teach the woman and her support person about the monitoring equipment and discuss any of their questions. c. Document the frequency, duration, and intensity of contractions measured by the external device. d. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place.

ANS: B Teaching is an essential part of the nurse's role. Corrective actions should be initiated first to correct abnormal findings as quickly as possible. Electronic monitoring will record the contractions and FHR response. The support person should still be encouraged to assist with the comfort measures.

If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen? a. Right upper b. Left upper c. Right lower d. Left lower

ANS: C If the fetus is in a right occiput anterior position, the fetal spine will be on the mother's right side. The best location to hear the fetal heart rate is through the fetal shoulder, which would be in the right lower quadrant. The right upper, left upper, and left lower areas are not the best locations for assessing the fetal heart rate in this case.

The physician has ordered an amnioinfusion for the laboring patient. Which data supports the use of this therapeutic procedure? a. Presenting part not engaged b. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) c. Breech position of fetus d. Twin gestation

b. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) Amnioinfusion is a procedure utilized during labor when cord compression or the detection of gross meconium staining is found in the amniotic fluid. An isotonic (Lactated Ringers or normal saline) solution is used as an irrigation method through the IUPC (intrauterine pressure catheter).

Which nursing action is correct when initiating electronic fetal monitoring? a. Lubricate the tocotransducer with an ultrasound gel. b. Securely apply the tocotransducer with a strap or belt. c. Inform the patient that she should remain in the semi-Fowler position. d. Determine the position of the fetus before attaching the electrode to the maternal abdomen.

b. Securely apply the tocotransducer with a strap or belt.

The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action at this time? a. Decrease the rate of the IV fluids. b. Document the fetal heart rate pattern. c. Explain to the patient that the pattern is normal. d. Perform a vaginal exam to detect a prolapsed cord.

d. Perform a vaginal exam to detect a prolapsed cord. Variable decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. A vaginal examination may identify a prolapsed cord, which may cause variable decelerations, bradycardia, or both as it is compressed. A vaginal examination also evaluates the woman's labor status, which helps the birth attendant decide if labor should continue. This is a Category III tracing (abnormal); therefore the IV rate should be increased and an intervention needs to occur.

The tocotransducer should be placed: a. In the suprapubic area. b. In the fundal area. c. Over the xiphoid process. d. Within the uterus.

b. In the fundal area

What is the most likely cause for this fetal heart rate pattern? a. Administration of an epidural for pain relief during labor b. Cord compression c. Breech position of fetus d. Administration of meperidine (Demerol) for pain relief during labor

ANS: B Variable deceleration patterns are seen in response to head compression or cord compression. A breech presentation would not be likely to cause this fetal heart rate pattern. Similarly, administration of medication and/or an epidural would not cause this fetal heart rate pattern.

The woman who uses cocaine is more likely to have which pattern on the electronic fetal heart monitor? a. Intermittent tachycardia b. Periodic accelerations c. Variable decelerations d. Late decelerations

A. Intermittent tachycardia

Which patient is a candidate for internal monitoring with an intrauterine pressure catheter? a. Obese patient whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds b. Gravida 1, para 0, whose contractions are 2 to 3 minutes apart, lasting 60 seconds c. Multigravida whose contractions are 2 minutes apart, lasting 60 to 70 seconds d. Gravida 2, para 1, in latent phase whose contractions are irregular and mild

ANS: A A thick layer of abdominal fat absorbs energy from uterine contractions, reducing their apparent intensity on the monitor strip. Contraction patterns of 2 to 3 minutes lasting 60 seconds and every 2 minutes lasting 60 to 70 seconds indicate accurate measurement of uterine activity. Irregular and mild contractions are common in the latent phase.

The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? a. Doppler b. Fetoscope c. Scalp electrode d. Tocodynamometer

ANS: A Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The tocodynamometer does not require gel. This device monitors uterine contractions.

When evaluating the patient's progress, the nurse knows that four of the five fetal factors that interact to regulate the heart rate are (Select all that apply.) a. baroreceptors. b. adrenal glands. c. chemoreceptors. d. uterine activity. e. autonomic nervous system.

ANS: A, B, C, E The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, whereas parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR, and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing accelerations in FHR. Hypertonic uterine activity can reduce the time available for the exchange of oxygen and waste products; however, this is a maternal factor. The fifth fetal factor is the central nervous system. The fetal cerebral cortex causes the heart rate to increase during fetal movement and decrease when the fetus sleeps.

The nurse is preparing supplies for an amnioinfusion on a patient with intact membranes. Which supplies should the nurse gather? (Select all that apply.) a. Extra underpads b. Solution of 3% normal saline c. Amniotic hook to perform an amniotomy d. Solid intrauterine pressure catheter with a pressure transducer on its tip

ANS: A, C Amnioinfusion is performedNwithRlacItateGd RBin.gCer'sMsolution or normal saline, not 3%. Normal saline is infused into the uterus through an intrauterine pressure catheter. The underpads must be changed regularly because fluid leaks out constantly. The membranes need to be ruptured before an amnioinfusion can be initiated so an amniotic hook will be needed. The IUPC must have a double lumen to run the infusion through.

The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor? a. Every 10 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes

ANS: C Evaluate the fetal monitoring strip systematically for the elements noted. The following are recommended assessment and documentation intervals for IA and EFM (although facility policies may be different): low-risk women, every 30 minutes during the active phase and every 15 minutes during the second stage.

Proper placement of the tocotransducer for electronic fetal monitoring is a. Inside the uterus. b. On the fetal scalp. c. Over the uterine fundus. d. Over the mother's lower abdomen.

ANS: C 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. The tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at the fundus; this is the best placement area.

The nurse is concerned that a patient's uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take? a. Reposition the tocotransducer. b. Reposition the Doppler transducer. c. Obtain an order from the health care provider for a spiral electrode. d. Obtain an order from the health care provider for an intrauterine pressure catheter.

ANS: D An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this would not be accurate with an obese patient, even with repositioning. A Doppler auscultates the FHR. A scalp electrode (or spiral electrode) measures the fetal heart rate (FHR).

The nurse should respond to incomplete uterine relaxation between contractions by: a. Increasing the rate of IV fluid. b. Having the woman push with contractions. c. Contacting the physician for a tocolytic order. d. Initiating an amnioinfusion with Ringer's lactate.

C. Contacting the physician for a tocolytic order

Firm contractions that occur every 2 to 21/2 minutes and last 100 seconds (1 minute, 40 seconds) may reduce fetal oxygen supply because they: a. Cause fetal bradycardia and reduce oxygen concentration. b. Activate the fetal sympathetic nervous system. c. Reduce time for oxygen exchange in the placenta. d. Suppress the normal variability of the fetal heart.

C. Reduce time for oxygen exchange in the placenta

Which of the following is the priority intervention for the patient in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? a. Administer O2 at 8 to 10 L/minute. b. Decrease the IV rate to 100 mL/hour. c. Reposition the ultrasound transducer. d. Perform a vaginal exam to assess for cord prolapse.

a. Administer O2 at 8 to 10 L/minute. A deceleration that returns to baseline after the end of the contraction is a late deceleration caused by placental perfusion problems. Administering oxygen will increase the patient's blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate, repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord prolapse are not effective interventions to improve fetal oxygenation.

The nurse notes a pattern of variable decelerations to 75 bpm on the fetal monitor. The initial nursing action should be to: a. Reposition the woman. b. Administer oxygen. c. Increase the intravenous (IV) infusion. d. Stimulate the fetal scalp.

a. Reposition the woman

Which maternal condition should be considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix dilated to 4 cm c. Fetus has known heart defect d. Maternal HIV

a. Unruptured membranes

The expected response of the fetal heart rate of a term fetus to movement is: a. Suppression of normal variability for at least 15 seconds. b. Acceleration of 15 or more beats per minute (bpm) for 15 seconds. c. Increase in variability by 15 bpm for 10 minutes. d. Acceleration followed by deceleration of the heart rate.

b. Acceleration of 15 or more beats per minute (bpm) for 15 seconds.

When a pattern of variable decelerations occur, the nurse should immediately a. administer O2 at 8 to 10 L/minute. b. place a wedge under the right hip. c. increase the IV fluids to 150 mL/hour. d. position patient in a knee-chest position.

d. position patient in a knee-chest position. Variable decelerations are caused by conditions that reduce flow through the umbilical cord. The patient should be repositioned when the FHR pattern is associated with cord compression. The knee-chest position uses gravity to shift the fetus out of the pelvis to relieve cord compression. Administering oxygen will not be effective until cord compression is relieved. Increasing the IV fluids and placing a wedge under the right hip are not effective interventions for cord compression.

The nurse notes a pattern of decelerations on the fetal monitor that begins shortly after the contraction begins and returns to baseline just before the contraction is over. The correct nursing response is to: a. Give the woman oxygen by face mask at 8 to 10 L/min. b. Position the woman on her opposite side. c. Increase the rate of the woman's IV fluid. d. Continue to observe and record the normal pattern.

d. Continue to observe and record the normal pattern.

Which clinical finding can be determined only by electronic fetal monitoring? a. Variability b. Tachycardia c. Bradycardia d. Fetal response to contractions

variability

Which method of intrapartum fetal monitoring is the most appropriate when a woman has a history of hypertension during pregnancy? a. Continuous auscultation with a fetoscope b. Continuous electronic fetal monitoring c. Intermittent assessment with a Doppler transducer d. Intermittent electronic fetal monitoring for 15 minutes each hour

b. Continuous electronic fetal monitoring

A woman is admitted in possible labor at 34 weeks of gestation. She is monitored with the external fetal monitor while on her left side. The nurse should periodically assess the contractions by palpation, primarily because: a. It makes the woman feel more like her pregnancy is normal. b. Palpation identifies whether the fetus has changed its presentation. c. Contractions may not be sensed by the tocotransducer while the woman is on her side. d. The tocotransducer is not accurate for actual intensity and uterine resting tone.

d. The tocotransducer is not accurate for actual intensity and uterine resting tone.

The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient's contractions. How will the nurse document these findings? a. Late decelerations b. Early decelerations c. Variable decelerations d. Proximal decelerations

ANS: A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contraction's peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal deceleration is not a recognized term.

The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.) a. Post-term fetus b. Maternal fever c. Placenta previa d. Induction of labor e. Prolonged rupture of membranes

ANS: B, C, E Fetal scalp stimulation is not done when there is maternal fever (possibility of introducing microorganisms into the uterus), placenta previa (placenta overlies the cervix, and hemorrhage is likely), or prolonged rupture of membranes (risk of infection). Fetal scalp stimulation may be used to evaluate a post-term fetus' response to stimulation. It is also used to evaluate a fetus when labor is being induced.

To clarify the fetal condition when baseline variability is absent, the nurse should first a. monitor fetal oxygen saturation using fetal pulse oximetry. b. notify the physician so that a fetal scalp blood sample can be obtained. c. apply pressure to the fetal scalp with a glove finger using a circular motion. d. increase the rate of nonadditive IV fluid to expand the mother's blood volume.

ANS: C Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An acceleration in response to the massage suggests that the fetus is in normal oxygen and acid-base balance. Monitoring fetal oxygen saturation using fetal pulse oximetry is no longer available in the United States. Obtaining a fetal scalp blood sample is invasive and the results are not immediately available. Increasing the rate of nonadditive IV fluid would not clarify the fetal condition.

Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength? a. External fetal monitoring (EFM) b. Internal fetal monitoring c. Intrauterine pressure catheter (IUPC) d. Maternal comments based on perception

ANS: C IUPC is a clinical tool that provides an accurate assessment of uterine contraction strength. EFM provides evidence of contraction pattern and fetal heart rate but only estimates uterine contraction strength. Internal fetal monitoring provides direct evidence of fetal heart rate and contraction pattern. It only estimates uterine contraction strength. Maternal comments related to pain may not be related to uterine contraction strength and thus are influenced by the client's own pain perception.

The patient presenting at 38 weeks' gestation, gravida 1, para 0, vaginal exam 4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern? a. Continue oxytocin (Pitocin) infusion. b. Contact the anesthesia department for epidural administration. c. Change maternal position. d. Administer Narcan to patient and prepare for immediate vaginal delivery.

ANS: C Late decelerations indicate fetal compromise (uteroplacental insufficiency) and are considered to be a significant event requiring immediate assessment and intervention. Of all the options listed, changing maternal position may increase placental perfusion. In the presence of late decelerations, Pitocin infusion should be stopped. Contacting anesthesia for epidural administration will not solve the existing problem of late decelerations. There are no data to support the administration of Narcan and because patient is still in early labor, birth is not imminent.

Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation? a. Inhibition of epinephrine b. Inhibition of norepinephrine c. Stimulation of the vagus nerve d. Sympathetic stimulation

ANS: D Sympathetic nerve innervation would result in an increase in fetal heart rate. The release of epinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. The release of norepinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. Stimulation of the vagus nerve would indicate parasympathetic innervation and result in a decreased heart rate.

Why is continuous electronic fetal monitoring generally used when oxytocin is administered? a. Fetal chemoreceptors are stimulated. b. The mother may become hypotensive. c. Maternal fluid volume deficit may occur. d. Uteroplacental exchange may be compromised.

ANS: D The uterus may contract more firmly and the resting tone may be increased with oxytocin use. This response reduces the entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Oxytocin affects the uterine muscles. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk.

The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? a. Administer oxygen with a face mask at 8 to 10 L/minute. b. Reposition the fetal monitor ultrasound transducer. c. Assist the patient to the bathroom to empty her bladder. d. Continue to monitor the patient and fetal heart rate patterns.

a. Administer oxygen with a face mask at 8 to 10 L/minute. Late decelerations are similar to early decelerations in that the FHR slows (30 to 40 bpm); however, the decelerations are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. They reflect possible impaired placental exchange (uteroplacental insufficiency). Administration of 100% oxygen through a snug face mask makes more oxygen available for transfer to the fetus. A commonly suggested rate is 8 to 10 L/minute. The pattern is abnormal, so repositioning the fetal ultrasound transducer, assisting the patient to the bathroom, or continuing to monitor the pattern will not correct the problem.

Which clinical finding would be considered normal for a preterm fetus during the labor period? a. Baseline tachycardia b. Baseline bradycardia c. Fetal anemia d. Acidosis

a. Baseline tachycardia Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should a. maintain the normal assessment routine. b. administer O2 at 8 to 10 L/minute by face mask. c. increase the IV flow rate from 125 to 150 mL/hour. d. assess the maternal blood pressure for a systolic pressure below 100 mm Hg.

a. maintain the normal assessment routine. Decelerations that mirror the contraction are early decelerations caused by fetal head compression. Early decelerations are not associated with fetal compromise and require no intervention. Administering O2, increasing the IV flow rate, and assessing for hypotension are not necessary within early decelerations.

A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action? a. Stop the infusion of Pitocin. b. Reposition the patient from her right to her left side. c. Perform a vaginal exam to assess for a prolapsed cord. d. Prepare the patient for an emergency cesarean birth.

a. Stop the infusion of Pitocin. There are multiple reasons for late decelerations. Address the probable cause first, such as uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations. Repositioning can increase oxygenation to the fetus but does not address the cause of the problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of moderate variability, the fetus continues to have adequate oxygen reserves. If a Category II (indeterminate) or III (abnormal) tracing is interpreted, a prompt approach to assessing oxygenation should be completed.

Choose the important precaution to be taken when a transducer-tipped intrauterine pressure catheter is used to monitor uterine contractions during labor. a. The pressure reflects the pressure of the fluid above, as well as the pressure of the contraction. b. The fluid that fills the catheter must be warmed to room temperature. c. Understand that pressures within the fluid-filled catheter are higher than those in the solid catheter. d. Fluid-filled catheters cannot be used when a spiral electrode is applied.

a. The pressure reflects the pressure of the fluid above, as well as the pressure of the contraction.

When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? a. Early decelerations b. Variable decelerations c. Nonperiodic accelerations d. Increase in baseline variability

b. Variable decelerations

When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? a. Reposition the patient. b. Apply a fetal scalp electrode. c. Record this normal pattern. d. Administer oxygen by nasal cannula.

c. Record this normal pattern.

Which of the following is the priority intervention for a supine patient whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? a. Increase IV infusion. b. Elevate lower extremities. c. Reposition to left side-lying position. d. Administer oxygen per face mask at 4 to 6 L/minute.

c. Reposition to left side-lying position. Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the patient is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the patient is in a supine position.

The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing a. a worsening hypoxia. b. progressive acidosis. c. an expected response. d. parasympathetic stimulation.

c. an expected response.

When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left side, which nursing action is indicated? a. Lower the head of the bed. b. Place a wedge under the left hip. c. Change her position to the right side. d. Place the mother in Trendelenburg position.

c. Change her position to the right side.

The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? a. This pattern reflects variable decelerations. No interventions are necessary at this time. b. Document this Category I fetal heart rate pattern and decrease the rate of the intravenous (IV) fluid. c. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. d. This deceleration pattern is associated with uteroplacental insufficiency. The nurse must act quickly to improve placental blood flow and fetal oxygen supply.

d. This deceleration pattern is associated with uteroplacental insufficiency. The nurse must act quickly to improve placental blood flow and fetal oxygen supply.