Maternity chapter 21: Intrapartum Nursing Assessment
Nursing intervention in Late deceleration
-place pt in left lateral position -increase primary iv flow rate -admin O2 througha face mask 10L/min -D/C oxytocin!!! assist with fetal blood sampling if ordered
The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse?
"I stimulated the top of the fetus's head to try to get his heart rate to accelerate."
The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important?
"The monitor helps us to see how the baby is tolerating labor."
A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching?
"The most important part of fetal heart monitoring is the presence of variability."
The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status?
"Who will be your labor support person?"
The client has been pushing for 3 hours, and the fetus is making a slow descent. The partner asks the nurse whether pushing for this long is normal. How should the nurse respond?
"Your baby is taking a little longer than average, but is making progress."
Nursing interventions for decreased variability
-reposition pt to the LEFT lateral position -admin IV fluids and O2 as ordered -anticipate order for fetal monitoring
This procedure helps determine the positioning and presentation of the fetus
leopold maneuvers
A client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus?
1)Auscultate the fetal heart rate between and during contractions. 2) Palpate contractions and resting uterine tone.
During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The client's partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following?
1)Cervical dilation and effacement 2) Presenting part
Fetal factors that possibly indicate electronic fetal monitoring include which of the following?
1)Decreased fetal movement 2)Meconium passage 3)Multiple gestation
Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following?
1)Early fetal hypoxia 2)Prolonged fetal stimulation 3)Fetal anemia 4)Infection
Before performing Leopold maneuvers, what would the nurse do?
1)Have the client lie on her back with her feet on the bed and knees bent. 2)Have the client empty her bladder.
results from mild hypoxia and fetal stimulation
increased variability
The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip?
Accelerations
The nurse is working with a pregnant adolescent. The client asks the nurse how the baby's condition is determined during labor. The nurse's best response is that during labor, the nurse will do which of the following?
Assess the fetus's heart rate with an electronic fetal monitor.
The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best?
Assist the client to change position.
The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician?
Dark red vaginal bleeding
Persistent early decelerations are noted. What would the nurse's first action be?
Do nothing. This is a benign pattern.
The primary care provider is performing a fetal scalp stimulation test. What result would the nurse hope to observe?
Fetal heart acceleration Reactivity associated with the stimulation
The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate?
Inform the maternal client that the rate is normal.
The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following?
Late decelerations
The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention?
Late decelerations with minimal variability
During a maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in what quadrant?
Left Lower Quadrant
The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following?
Maternal hypotension Prolonged umbilical cord compression Fetal dysrhythmia Late fetal asphyxia
The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first?
Perform Leopold maneuvers to determine fetal position.
After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what?
Prepare the mother for a higher-risk delivery.
A laboring client asks the nurse, "Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor?" The nurse would accurately explain that the best rationale for using an IUPC is which of the following?
The IUPC provides more accurate data than does the tocodynamometer.
After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following?
Umbilical cord compression
The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention?
Woman at 7 cm, fetal heart tones auscultated every 90 minutes
occurs from fetal movement or contractions
accelerations
Nursing intervention for increased variability
carefully evaluate FHR looking for s/s of distress
results from hypoxia, acidosis, CNS depression, medication
decreased variability
results from head compression
early decelerations
How should the pt be placed position wise for a leopold maneuver?
on the back with feet and knees bent slightly ** pt should void prior to
The nurse has just palpated contractions and compares the consistency to that of the forehead to estimate the firmness of the fundus. What would the intensity of these contractions be identified as?
strong
this occurs from umbilical cord compressions
variable decelerations
The nurse is preparing to assess a laboring client who has just arrived in the labor and birth unit. Which statement by the client indicates that additional education is needed?
"After you assess my pelvis, you will be able to tell when I will deliver."
The nurse is caring for a client who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include which of the following?
1)Fetal anemia 2)Chronic fetal bleeding 3)Twin-to-twin transfusion 4) Umbilical cord occlusion
The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following?
1)Maternal dehydration 2)Maternal hyperthyroidism 3)Fetal hypoxia 4) Prematurity
The nurse is caring for a client in the transition phase of labor and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation?
1)Provide caring labor support. 2)Reassure the client and her partner that she is doing fine.
The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse?
After determining where the back is located, the cervix is assessed.
A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately?
Begin continuous fetal heart rate monitoring.
The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best?
Document the fetal heart rate.
results from utero placenal insufficiency
late decelerations
