18 Fetal Assessment (Labor)

MATCHING Fetal well-being in labor can be measured by the response of the FHR to uterine contractions. Match the characteristic of normal uterine activity during labor with the correct description. a. Frequency b. Duration c. Strength d. Resting tone e. Relaxation time 1. Commonly 45 seconds or more in the second stage of labor 2. Generally ranging from two to five contractions per 10 minutes of labor 3. Average of 10 mm Hg 4. Peaking at 40 to 70 mm Hg in the first stage of labor 5. Remaining fairly stable throughout the first and second stages

1. ANS: E; 2. ANS: A 3. ANS: D 4. ANS: C 5. ANS: B

Which characteristic correctly matches the type of deceleration with its likely cause? a. Early deceleration----umbilical cord compression b. Late decelerations—uteroplacental insufficiency c. Variable decelerations—head compression d. Prolonged deceleration—unknown cause

ANS: B Late deceleration is caused by uteroplacental insufficiency. 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.

6. Which alteration in the FHR pattern would indicate the potential need for an amnioinfusion? a. Variable decelerations b. Late decelerations c. Fetal bradycardia d. Fetal tachycardia

ANS: A 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. Late decelerations are unresponsive to amnioinfusion. Amnioinfusion is not appropriate for treatment of fetal bradycardia. Amnioinfusion has no bearing on fetal tachycardia.

13. Which statement best describes a normal uterine activity pattern in labor? a. Contractions every 2 to 5 minutes b. Contractions lasting about 2 minutes c. Contractions about 1 minute apart d. A contraction intensity of about 500 mm Hg with relaxation at 50 mm Hg

ANS: A Contraction frequency overall generally ranges from two to five per 10 minutes of labor, with lower frequencies during the first stage and higher frequency seen during the second stage. Contraction duration remains fairly stable throughout the first and second stages, ranging from 45 to 80 seconds, not generally exceeding 90 seconds. Contractions 1 minute apart are too often, and this would be considered an abnormal labor pattern. Intensity of uterine contractions generally ranges from 25 to 50 mm Hg in the first stage of labor and may rise to more than 80 mm Hg in the second stage.

What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: A Early decelerations are the fetus's response to fetal head compression. These are considered benign and interventions are not necessary. 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 (FHR) unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

2. Which clinical finding or intervention might be considered the rationale for fetal tachycardia to occur? a. Maternal fever b. Umbilical cord prolapse c. Regional anesthesia d. Magnesium sulfate administration

ANS: A Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. Umbilical cord prolapse,Regional anesthesia, and Magnesium sulfate administration will most likely result in fetal bradycardia, not tachycardia.

Which client would not be a suitable candidate for internal EFM?: a. A client who still has intact membranes b. A woman whose fetus is well engaged in the pelvis c. A pregnant woman who has a comorbidity of obesity d. A client whose cervix is dilated to 4 to 5 cm

ANS: A For internal monitoring, the membranes must have ruptured and the cervix must be sufficiently dilated. The presenting part must be low enough to allow placement of the spiral electrode necessary for internal monitoring. The accuracy of internal monitoring is not affected by maternal size. It may be more difficult to evaluate fetal well-being using external EFM on an obese client. This client is indeed a candidate for internal monitoring. The cervix must be at least 2 to 3 cm dilated.

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: a. Change the woman's position b. Notify the health care provider c. Assist with amnioinfusion d. Insert a scalp electrode

ANS: A Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, the nurse should continue with subsequent intrauterine resuscitation measures, including notifying the health care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The fetal heart rate pattern associated with this situation most likely will reveal variable decelerations. A fetal scalp electrode provides accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that will alleviate late decelerations, nor is it the nurse's first priority.

Which nursing intervention would result in an increase in maternal cardiac output? a. Change in position b. Oxytocin administration c. Regional anesthesia d. IV analgesic

ANS: A 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 position 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 to avoid the supine position. Oxytocin administration, regional anesthesia, and IV analgesic may reduce maternal cardiac output.

What are the legal responsibilities of the perinatal nurses? a. Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes b. Greeting the client on arrival, assessing her, and starting an IV line c. Applying the external fetal monitor and notifying the health care provider d. Making sure the woman is comfortable

ANS: A 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. Greeting the client on arrival, assessing her, and starting an IV line are activities that should be performed when any client arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions. Applying the external fetal monitor and notifying the health care provider is a nursing function that is part of the standard of care for all obstetric clients. This falls within the RN scope of practice. Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable.

What is the correct placement of the tocotransducer for effective EFM? a. Over the uterine fundus b. On the fetal scalp c. Inside the uterus d. Over the mother's lower abdomen

ANS: A 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.

23. Part of the nurse's role is assisting with pushing and positioning. Which guidance should the nurse provide to her client in active labor? a. Encourage the woman's cooperation in avoiding the supine position b. Advise the woman to avoid the semi-Fowler position c. Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response d. Instruct the woman to open her mouth and close her glottis, letting air escape after the push

ANS: A 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. Encouraging the woman to hold her breath and tighten her abdominal muscles is the Valsalva maneuver, which should be avoided. Both the mouth and glottis should be open, letting air escape during the push.

The client has delivered by urgent caesarean birth for fetal compromise. Umbilical cord gases were obtained for acid-base determination. The pH is 6.9, partial pressure of carbon dioxide (PCO2) is elevated, and the base deficit is 11 mmol/L. What type of acidemia is displayed by the infant? a. Respiratory b. Metabolic c. Mixed d. Turbulent

ANS: A These findings are evidence of respiratory acidemia. Metabolic acidemia is expressed by a pH <7.20, normal carbon dioxide pressure, and a base excess of 12 mmol/L. Mixed acidemia is evidenced by a pH <7.20, elevated carbon dioxide pressure, and a base excess of 12 mmol/L. There is no such finding as turbulent acidemia.

A nurse caring for a woman in labor should understand that absent or minimal variability is classified as either abnormal or indeterminate. Which condition related to decreased variability is considered benign? a. A periodic fetal sleep state b. Extreme prematurity c. Fetal hypoxemia d. Preexisting neurologic injury

ANS: A When the fetus is temporarily in a sleep state there is minimal variability present. Periodic fetal sleep states usually last no longer than 30 minutes. A woman who presents in labor with extreme prematurity may display a fetal heart rate (FHR) pattern of minimal or absent variability. Abnormal variability may also be related to fetal hypoxemia and metabolic acidemia. Congenital anomalies or preexisting neurologic injury may also present as absent or minimal variability. Other possible causes might be central nervous system (CNS) depressant medications, narcotics, or general anesthesia.

In assessing the immediate condition of the newborn after birth, a sample of cord blood may be a useful adjunct to the Apgar score. Cord blood is then tested for pH, carbon dioxide, oxygen, and base deficit or excess. Which clinical situation warrants this additional testing? (Select all that apply.) a. Low 5-minute Apgar score b. Intrauterine growth restriction (IUGR) c. Maternal thyroid disease d. Intrapartum fever e. Vacuum extraction

ANS: A, B, C, D, The American College of Obstetricians and Gynecologists (ACOG) suggests obtaining cord blood values in all of these clinical situations. Samples can be drawn from both the umbilical artery and the umbilical vein. Results may indicate that fetal compromise has occurred.

What three measures should the nurse implement to provide intrauterine resuscitation? a. Call the provider, reposition the mother, and perform a vaginal exam. b. Turn the client onto her side, provide oxygen (O2) via face mask, and increase intravenous (IV) fluids. c. Administer oxygen to the mother, increase IV fluid, and notify the health care provider. d. Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.

ANS: B Basic interventions for management of any abnormal fetal heart rate pattern includes administer oxygen by nonrebreather face mask at a rate of 8 to 10 L/min, assist the woman to a side-lying (lateral) position, and increase blood volume by increasing the rate of the primary IV infusion. The purpose of these interventions is to improve uterine blood flow and intervillous space blood flow and increase maternal oxygenation and cardiac output. The term intrauterine resuscitation is sometimes used to refer to these interventions. Basic corrective measures include providing O2, instituting maternal position changes, and increasing IV fluid volume. If these interventions do not resolve the fetal heart rate issue quickly, the primary provider should be notified immediately. In this scenario the nurse failed to alter the woman's position. To improve uterine blood flow, the woman should be repositioned onto her side. If these interventions do not resolve the fetal heart rate issue quickly, the primary provider should be notified immediately. Performing a vaginal examination would not be helpful at this time. In this scenario the nurse should have begun by applying O2 at 8 to 10 L/min by nonrebreather face mask.

A new client and her partner arrive on the labor, delivery, recovery, and postpartum (LDRP) unit for the birth of their first child. The nurse applies 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. What is the nurse's best response?: a. "Don't worry about that machine; that's my job." b. "The baby's heart rate will fluctuate in response to what is happening during labor." c. "The top line graphs the baby's heart rate, and the bottom line lets me know how strong the contractions are." d. "Your doctor will explain all of that later."

ANS: B Explaining what indicates a normal fetal heart rate educates the partner about fetal monitoring and provides support and information to alleviate his fears. Telling the partner not to worry discredits his feelings and does not provide the teaching he is requesting. Telling the partner that the graph indicates how strong the contractions are provides inaccurate information and does not address the partner's concerns about the fetal heart rate. The fetal monitor graphs the frequency and duration of the contractions, not the intensity. Nurses should take every opportunity to provide client and family teaching, especially when information is requested.

During labor a fetus with an average (FHR) of 135 beats/min over a 10-minute period is considered to have: a. Bradycardia b. A normal baseline heart rate c. Tachycardia d. Hypoxia

ANS: B The baseline heart rate is measured over 10 minutes; a normal range is 110 to 160 beats/min. Bradycardia is a FHR less than 110 beats/min for 10 minutes or longer. Tachycardia is a FHR more than 160 beats/min for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of this condition exists with a baseline heart rate in the normal range

What is the most likely cause for variable FHR decelerations? a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Fetal hypoxemia

ANS: B Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in the FHR. Fetal hypoxemia results in tachycardia initially, then bradycardia if hypoxia continues.

Which FHR decelerations would require the nurse to change the maternal position? (Select all that apply.) a. Early decelerations b. Late decelerations c. Variable decelerations d. Moderate decelerations e. Prolonged decelerations

ANS: B, C, E Early decelerations (and accelerations) do not generally need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral). Variable decelerations also require a maternal position change (side to side). Moderate decelerations are not an accepted category. Prolonged decelerations are late or variable decelerations that last for a prolonged period (longer than 2 minutes) and require intervention.

A tiered system of categorizing FHR has been recommended by professional organizations. 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. What is the correct nomenclature for these categories? (Select all that apply.) a. Reassuring b. Category I c. Category II d. Nonreassuring e. Category III

ANS: B, C, E The three-tiered system of FHR tracings include category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate and includes tracings that do not meet category I or III criteria. Category III tracings are abnormal and require immediate intervention.

According to the National Institute of Child Health and Human Development (NICHD) Three-Tier System of Fetal Heart Rate Classification, category III tracings include all fetal heart rate (FHR) tracings not categorized as category I or II. Which characteristics of the fetal heart rate belong in category III? a. Baseline rate of 110 to 160 beats/min b. Tachycardia c. Absent baseline variability not accompanied by recurrent decelerations d. Variable decelerations with other characteristics such as shoulders or overshoots e. Absent baseline variability with recurrent variable decelerations f. Bradycardia

ANS: B, D, E, F Tachycardia, variable decelerations with other characteristics, absent baseline variability with recurrent variable decelerations, and bradycardia are characteristics that are considered nonreassuring or abnormal and belong in category III. A fetal heart rate of 110 to 160 beats/min is considered normal and belongs in category I. Absent baseline variability not accompanied by recurrent decelerations is a category II characteristic.

. In which clinical situation would the nurse most likely anticipate a fetal bradycardia? a. Intraamniotic infection b. Fetal anemia c. Prolonged umbilical cord compression d. Tocolytic treatment using terbutaline

ANS: C 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. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

The nurse who provides care to clients in labor must have a thorough understanding of the physiologic processes of maternal hypotension. Which outcome might occur if the interventions for maternal hypotension are inadequate? a. Early decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: C Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early decelerations. Maternal hypotension is not associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.

The nurse observes a sudden increase in variability on the ERM tracing. Which class of medications may cause this finding? a. Narcotics b. Barbiturates c. Methamphetamines d. Tranquilizers

ANS: C Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; whereas methamphetamines may cause increased variability.

Which information related to a prolonged deceleration is important for the labor nurse to understand? a. Prolonged decelerations present a continuing pattern of benign decelerations that do not require intervention. b. Prolonged decelerations constitute a baseline change when they last longer than 5 minutes. c. A disruption to the fetal oxygen supply causes prolonged decelerations. d. Prolonged decelerations require the customary fetal monitoring by the nurse.

ANS: C Prolonged decelerations are caused by a disruption in the fetal oxygen supply. They usually begin as a reflex response to hypoxia. If the disruption continues, then the fetal cardiac tissue, itself, will become hypoxic, resulting in direct myocardial depression of the FHR. Prolonged decelerations can be caused by prolonged cord compression, uteroplacental insufficiency, or perhaps sustained head compression. Prolonged decelerations lasting longer than 10 minutes are considered a baseline change that may require intervention. A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in the FHR of at least 15 beats per minute below the baseline and lasting longer than 2 minutes but shorter than 10 minutes. Nurses should immediately notify the physician or nurse-midwife and initiate appropriate treatment of abnormal patterns when they see prolonged decelerations.

What is a distinct advantage of external EFM? a. The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the fetal heart rate (FHR). b. The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs). c. The tocotransducer is especially valuable for measuring uterine activity (UA) during the first stage of labor. d. Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.

ANS: C The tocotransducer is valuable for measuring uterine activity during the first stage of labor. This is especially true when the membranes are intact. Short-term variability and beat-to-beat changes cannot be measured with this technology. The tocotransducer cannot measure and record the intensity of UCs. The transducer must be repositioned when the woman or the fetus changes position.

5. The nurse providing care for a high-risk laboring woman is alert for late FHR decelerations. Which clinical finding might be the cause for these late decelerations? a. Altered cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Meconium fluid

ANS: C Uteroplacental insufficiency results in late decelerations in the FHR. Altered fetal cerebral blood flow results in early decelerations in the FHR. Umbilical cord compression results in variable decelerations in the FHR. Meconium-stained fluid may or may not produce changes in the fetal heart rate, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.

5. The baseline 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 client's most recent 10-minute segment on the monitor strip and notes a late deceleration. Which is likely to have caused this change? (Select all that apply.) a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the baby's neck e. Maternal supine hypotension

ANS: C, E Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure, and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and the placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression, which may happen when the umbilical cord is around the baby's neck, arm, leg, or other body part or when a short cord, a knot in the cord, or a prolapsed cord is present.

19. Which definition of an acceleration in the fetal heart rate (FHR) is accurate? a. FHR accelerations are indications of fetal well-being when they are periodic. b. FHR accelerations are greater and longer in preterm gestations. c. FHR accelerations are usually observed with breech presentations when they are episodic. d. An acceleration in the FHR presents a visually apparent and abrupt peak.

ANS: D Acceleration of the FHR is defined as a visually apparent abrupt (only to peak 30 seconds) increase in the FHR above the baseline rate. Periodic accelerations occur with uterine contractions and are usually observed with breech presentations. Episodic accelerations occur during fetal movement and are indications of fetal well-being. Preterm accelerations peak at 10 beats per minute above the baseline and last for at least 10 seconds.

29. What physiologic change occurs as the result of increasing the infusion rate of nonadditive IV fluids? a. Maintaining normal maternal temperature b. Preventing normal maternal hypoglycemia c. Increasing the oxygen-carrying capacity of the maternal blood d. Expanding maternal blood volume

ANS: D Filling the mother's vascular system increases the amount of blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

Which FHR finding is the most concerning to the nurse who is providing care to a laboring client? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/min d. Late decelerations

ANS: D Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected. Accelerations in the FHR are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they generally are not a concern during normal labor. An FHR finding of 126 beats/min is normal and not a concern.

The nurse is using intermittent auscultation (IA) to locate the fetal heartbeat. Which statement regarding this method of surveillance is accurate? a. The nurse can be expected to cover only two or three clients when IA is the primary method of fetal assessment. b. The best course is to use the descriptive terms associated with electronic fetal monitoring (EFM) when documenting results c. If the heartbeat cannot be found immediately, a shift must be made to EFM. d. Ultrasound can be used to find the FHR and reassure the mother if initial difficulty was a factor

ANS: D Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if that device is used to help locate the heartbeat. When used as the primary method of fetal assessment, IA requires a nurse-to-client ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate. Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if that device is used to help locate the heartbeat.

11. The perinatal nurse realizes that an FHR that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with which condition? a. Hypotension b. Cord compression c. Maternal drug use d. Hypoxemia

ANS: D 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.

In which situation would the nurse be called on to stimulate the fetal scalp? a. As part of fetal scalp blood sampling b. In response to tocolysis c. In preparation for fetal oxygen saturation monitoring d. To elicit an acceleration in the fetal heart rate (FHR)

ANS: D 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 stimulates the fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxation of the uterus. The nurse stimulates the fetal scalp to elicit an acceleration of the FHR. Fetal oxygen saturation monitoring involves the insertion of a sensor. The nurse stimulates the fetal scalp to elicit an acceleration of the FHR.

The nurse is evaluating the EFM tracing of the client who is in active labor. Suddenly, the FHR drops from its baseline of 125 down to 80 beats per minute. The mother is repositioned, and the nurse provides oxygen, increased IV fluids, and performs a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take next? a. Call for help. b. Insert a Foley catheter. c. Start administering Pitocin. d. Immediately notify the care provider.

ANS: D To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluids, and provide oxygen. If oxytocin is infusing, then it should be discontinued. If the FHR does not resolve, then the primary care provider should be immediately notified. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, then a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. The administration of Pitocin may place additional stress on the fetus.