Chapter 19: Fetal health surveillance during labour Flashcards
(38 cards)
- A nurse determines that fetal bradycardia is present. What would the nurse expect is causing this?
a. Intra-amniotic infection
b. Fetal anemia
c. Prolonged umbilical cord compression
d. Treatment with atropine
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. Intra-amniotic infection, fetal anemia, and treatment with atropine would most likely result in fetal tachycardia.
- While evaluating an external monitor tracing of a patient in active labour, a nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate after the contraction has started, with the nadir of the decelerations occurring after the peak of the contraction. What is the nurse’s priority intervention?
a. Change the patient’s position.
b. Notify the 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 patient turns on their 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 would continue with subsequent intrauterine resuscitation measures, including notifying the care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. A fetal scalp electrode would provide accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurse’s first priority.
- A nurse is aware that which is a cause of early decelerations?
a. Transient fetal head compression
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. 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 unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.
- A nurse providing care for a laboring patient understands that which is true in relation to accelerations with fetal movement?
a. They are considered normal.
b. They are caused by umbilical cord compression.
c. They warrant close observation.
d. They are caused by uteroplacental insufficiency.
ANS: A
Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being and are considered normal. FHR interpretation is classified as normal, atypical, or abnormal. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.
- The nurse providing care for the labouring patient realizes that variable fetal heart rate (FHR) decelerations are caused by
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 would result in early decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the FHR. Fetal hypoxemia would result in tachycardia initially and then bradycardia if hypoxia continues.
- What should a nurse who is providing care for the labouring patient understand about late fetal heart rate (FHR) decelerations are related to?
a. Altered cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Meconium fluid
ANS: C
Uteroplacental insufficiency would result in late decelerations in the FHR. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Umbilical cord compression would result in variable decelerations in the FHR. Meconium-stained fluid may or may not produce changes in the FHR, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.
- When providing care for the labouring patient, which fetal heart rate (FHR) deviation should a nurse understand that amnioinfusion is used to treat?
a. Variable decelerations
b. Late decelerations
c. Fetal bradycardia
d. Fetal tachycardi
ANS: A
Amnioinfusion is used during labour to either dilute meconium-stained amniotic fluid or supplement the amount of amniotic fluid to reduce the severity of variable decelerations caused by cord compression. Amnioinfusion has no bearing on late decelerations, fetal bradycardia, or fetal tachycardia alterations in FHR tracings.
- What should a nurse assess for when caring for the patient in labour who experiences maternal hypotension?
a. Early decelerations
b. Fetal dysrhythmias
c. Fetal hypoxemia
d. Spontaneous rupture of membranes
ANS: C
Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension is not associated with early decelerations, fetal dysrhythmias, or spontaneous rupture of membranes.
- When caring for a labouring patient, a nurse is aware that which can lead to an increase in maternal cardiac output?
a. Change in position
b. Oxytocin administration
c. Regional anaesthesia
d. Intravenous 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 patient is in a supine position. This reduces venous return to the patient’s heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the patient to change positions and avoid the supine position. Oxytocin administration, regional anaesthesia, and intravenous analgesic may reduce maternal cardiac output.
- While evaluating an external monitor tracing of a patient in active labour whose labour is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. What should the nurse do?
a. Change the patient’s position.
b. Discontinue the oxytocin infusion.
c. Insert an internal monitor.
d. Document the finding in the patient’s record.
ANS: D
The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings.
- Which fetal heart rate (FHR) finding would concern the nurse during labour?
a. Accelerations with fetal movement
b. Early decelerations
c. An average FHR of 116 beats/min
d. Late decelerati
ANS: D
Late decelerations are generally caused by uteroplacental insufficiency and are associated with fetal hypoxemia; however, there are other causal factors. 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 labour. This FHR finding is normal and not a concern.
- Which is a common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less?
a. Altered cerebral blood flow
b. Fetal hypoxemia
c. Umbilical cord compression
d. Fetal sleep cycles
ANS: D
A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Fetal hypoxemia would be evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be seen. Umbilical cord compression would result in variable decelerations in the FHR.
- Which would a nurse understand best assesses fetal well-being during labour?
a. The response of the fetal heart rate (FHR) to labour
b. Maternal pain control
c. Accelerations in the FHR
d. An FHR above 110 beats/min
ANS: A
Fetal well-being during labour can be measured by the response of the FHR to uterine contractions. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labour. Although FHR accelerations are normal, they are only one component of the criteria by which fetal well-being is assessed. Likewise, an FHR above 110 beats/min may be reassuring but is also only one component of the criteria by which fetal well-being is assessed. More information would be needed to determine fetal well-being.
- The nurse is evaluating the fetal monitor tracing of a patient who is in active labour. Suddenly the fetal heart rate (FHR) drops from its baseline of 125 down to 80. The nurse repositions the mother, 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. What is the next nursing action the nurse take?
a. Recheck the vaginal examination.
b. Insert a Foley catheter.
c. Start oxytocin.
d. Notify the care provider immediately.
ANS: D
To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a atypical or abnormal pattern, a Caesarean birth may be warranted, which would require a Foley catheter. However, the physician must make that determination. Oxytocin may put additional stress on the fetus. Rechecking the vaginal examination after 5 minutes would not be the priority.
- What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken.
a. Call the provider, reposition the mother, and perform a vaginal examination.
b. Reposition the mother, increase intravenous (IV) fluid, and perform a vaginal
examination.
c. Administer oxygen to the mother, increase IV fluid, and notify the care provider.
d. Perform a vaginal examination, reposition the mother, and provide oxygen via
face mask.
ANS: B
Repositioning the mother, increasing IV fluid, and performing a vaginal examination are correct nursing actions for intrauterine resuscitation. The nurse should initiate intrauterine resuscitation in a compression, airway, breathing (CAB) manner, similar to basic life support. The first priority is to open the maternal and fetal vascular systems by repositioning the mother for improved perfusion. The second priority is to increase blood volume by increasing the IV fluid. The third priority is to perform a vaginal examination to assess progress in labour or relieve pressure of the presenting part on the cord. Administration of oxygen (8 to 10 L/min) by mask can be considered, although there is little evidence to evaluate its effectiveness when used in the management of suspected fetal compromise. If these interventions do not resolve the fetal heart rate issue quickly, the primary health care provider should be notified immediately.
- Which is a legal responsibility of the perinatal nurse?
a. Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate
nursing interventions, and documenting the outcomes
b. Greeting the patient on arrival, assessing them, and starting an intravenous (IV)
line
c. Applying the external fetal monitor and notifying the care provider
d. Making sure that the patient is comfortable and orientated to the unit
ANS: A
Nurses who care for patients 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 patient, assessing her, and starting an IV; applying the external fetal monitor and notifying the care provider; and making sure the patient is comfortable and orientated to the unit may be activities that a nurse performs, but are not activities for which the nurse is legally responsible.
- A perinatal nurse, understands that which accompanies a fetal heart rate that demonstrates late decelerations?
a. Hypotension
b. Cord compression
c. Maternal drug use
d. Hypoxemia
ANS: D
Late decelerations 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.
- A patient and their partner arrive on the labour and birth unit for the birth of their first child. A nurse applies the electronic fetal monitor (EFM) to the patient. The partner asks a nurse 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 basis of the nurse’s response?
a. Labour support people do not need to know about EFM interpretation.
b. The top line graphs the baby’s heart rate, which is between 110 and 160 but fluctuates somewhat.
c. The top line graphs the baby’s heart rate, and the bottom line lets the nurse know how strong the contractions are.
d. Arrange for the health care provider to explain interpretation to the patient’s partner.
ANS: B
Basing the response on factual information, that the top line graphs the baby’s heart rate, which is between 110 and 160 but fluctuates somewhat, educates the partner about fetal monitoring and provides support and information to alleviate his fears. Basing the response on not providing information discredits the partner’s feelings and does not provide the teaching they are requesting. Basing the response on inaccurate information, that is, the top line graphs the baby’s heart rate and the bottom line lets the nurse know how strong the contractions are, is not appropriate and does not address the partner’s concerns about the fetal heart rate. Also, the bottom line does not indicate how strong the contractions are but only how far apart the contractions are and how long they last. The EFM graphs the frequency and duration of the contractions, not the intensity. Nurses should take every opportunity to provide patient and family teaching, especially when information is requested.
- A nurse is aware that which characterizes a normal uterine activity pattern in labour?
a. Contractions every 2 to 5 minutes
b. Contractions lasting about 2 minutes
c. Contractions about 1 minute apart
d. Firm resting tone between contractions
ANS: A
Contractions normally occur every 2 to 5 minutes and last less than 90 seconds with about 30 seconds in between. The resting tone should be soft between contractions.
- According to the SOGC, how often should nurses auscultate the fetal heart rate (FHR)?
a. Every hour in the active phase of the first stage of labour in the absence of risk
factors
b. Every 20 minutes in the second stage, regardless of whether risk factors are
present
c. After rupture of membranes
d. More often in a patient’s first pregnancy
ANS: C
The FHR should be auscultated before and after administration of medications and induction of anaesthesia. In the active phase of the first stage of labour, the FHR should be auscultated every 15 to 30 minutes. In the second stage of labour the FHR should be auscultated every 5 minutes or after each contraction. The fetus of a first-time mother is not at increased risk and does not require increased monitoring.
- When using intermittent auscultation (IA) for fetal heart rate, what should the nurse be aware of?
a. The nurse can be expected to cover only two or three patients 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. A doptone can be used to find the fetal heartbeat.
ANS: D
Locating fetal heartbeats often takes time. A doptone (a portable ultrasound fetoscope) can be used to help locate the heartbeat. Mothers can be reassured verbally and by the ultrasound pictures if ultrasound is used to help locate the heartbeat. When used as the primary method of fetal assessment, auscultation requires a nurse-to-patient ratio of one to one. Documentation should include only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate.
- When using intermittent auscultation (IA) to assess uterine activity, the nurse should be cognizant that
a. the examiner’s hand should be placed over the fundus before, during, and after
contractions.
b. the frequency and duration of contractions is measured in seconds for
consistency.
c. contraction intensity is given a number of 1 to 7 by the patient.
d. the resting tone between contractions is described as either placid or turbulent.
ANS: A
The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.
- The uterine contractions of a patient early in the active phase of labour are assessed by an internal uterine pressure catheter (IUPC). A nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, what should the nurse do first?
a. Notify the patient’s primary health care provider immediately.
b. Prepare to administer oxytocin to stimulate uterine activity.
c. Document the findings, as they are considered normal for this phase.
d. Prepare the patient for onset of the second stage of labour.
ANS: C
The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse would document these findings in the patient’s medical record. This labour pattern indicates that the patient is in the active phase of the first stage of labour. Nothing indicates a need to notify the primary care provider at this time. Oxytocin augmentation is not needed for this labour pattern; this contraction pattern indicates adequate active labour. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labour. The transition phase precedes the second stage of labour, or delivery of the fetus.
- Which deceleration of the fetal heart rate would not require the nurse to change the maternal position?
a. Early decelerations
b. Late decelerations
c. Variable decelerations
d. It is always a good idea to change the patient’s position
ANS: A
Early decelerations (and accelerations) generally do not 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). Although changing positions throughout labour is recommended, it is not required in response to early decelerations.
