Chapter 14: Intrapartal
Normal oxygen saturation of a healthy fetus is 30% to _____%
70%
Brady FHR
<110 lasting >10 mins
Tachy FHR
>160 lasting >10 mins
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? A) Inspect the perineum. B) Auscultate the fetal heart tones. C) Time the contractions. D) Contact the primary care provider.
A) Inspect the perineum.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? A) Turn her or ask her to turn to her side. B) Administer oxygen at 3 to 4 L by nasal cannula. C) Help the woman to sit up in a semi-Fowler's position. D) Ask her to pant with the next contraction.
A) Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.
Which intervention would be least effective in caring for a woman who is in the transition phase of labor? A) providing one-to-one support B) having the client breathe with contractions C) encouraging the woman to ambulate D) urging her to focus on one contraction at a time
C) encouraging the woman to ambulate
Baseline for FHR
110-160 bpm
The fetal heart rate is heard most clearly at the fetal ________
back
__________fetal heart rate refers to the average fetal heart rate that occurs during a 10-minute period.
baseline
A _________ refers to a transient fall in fetal heart rate due to stimulation of the parasympathetic nervous system.
deceleration
The_______ is used during external electronic monitoring to detect changes in uterine pressure.
tocotransducer
The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? A) Continuous support through the labor process helps decrease the need for pain medication. B) A quick epidural can replace the need for pain medication. C) Sitting in a hot tub helps decrease the need for pain medication. D) Lying on an ice pack can help decrease the need for pain medication.
A) Continuous support through the labor process helps decrease the need for pain medication.
criteria for internal FHR
-ruptured membranes -cervical dilation of at least 2 cm -present fetal part low enough for placement of scalp electrode -skilled practitioner available to insert spinal electrode
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth? A) "The baby is coming. I'll explain what's happening and guide you." B) "Even though the baby is coming, the health care provider will be here soon." C) "Do you want me to call in your family?" D) "The baby is coming. Relax and everything will turn out fine."
A) "The baby is coming. I'll explain what's happening and guide you."
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? A) Elevate her hips to prevent cord prolapse. B) Assess fetal heart rate for fetal safety. C) Test a sample of amniotic fluid for protein. D) Ask her to bear down with the next contraction.
B) Assess fetal heart rate for fetal safety. Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.
A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure? A) To aid the woman as she pushes during labor B) To prevent supine hypotension syndrome C) To decrease the heart rate of the fetus D) To prevent the woman from falling out of bed
B) To prevent supine hypotension syndrome placing the woman in semi-Fowler position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to help prevent her uterus from compressing the vena cava and causing supine hypotension syndrome during the test.
Continuous external fetal monitoring involves the use of a spiral electrode. T/F
F
The length of the cervix assessed during a vaginal examination determines cervical dilation. T/F
False
A fetal heart rate of 140 beats per minute would be considered within the normal range. T/F
T
The nurse assesses fetal heart rate at least every 15 to 30 minutes during the active phase of labor. T/F
T
Marked variability
fluctuation range >25 BPM *same as absent/minimal-not good
moderate variability
fluctuation range from 6-25 BPM *normal
minimal variability
fluctuation range observed at <5 BPM *cord compression, premature, typically bad outcomes
Absent variability
fluctuation range undetectable *cord compression, premature, typically bad outcomes