Exam 2 - Chapter 18 Flashcards
A nurse caring for a laboring woman is cognizant that early decelerations are caused by: a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Spontaneous rupture of membranes
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.
Fetal tachycardia is most common during: a. Maternal fever b. Umbilical cord prolapse c. Regional anesthesia d. Magnesium sulfate administration
A - Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection.
Umbilical cord prolapse will most likely result in fetal bradycardia, not tachycardia.
Regional anesthesia will most likely result in fetal bradycardia, not tachycardia.
Magnesium sulfate administration will most likely result in fetal bradycardia, not tachycardia.
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
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.
The nurse providing care for the laboring woman understands 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
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
The nurse providing care for a high risk laboring woman is alert for late fetal heart rate (FHR) decelerations. These late decelerations may be caused by: a. Altered cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Meconium fluid
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.
A nurse providing care for a laboring woman understands that amnioinfusion is used to treat: a. Variable decelerations b. Late decelerations c. Fetal bradycardia d. Fetal tachycardia
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.
Which fetal heart rate (FHR) finding concerns the nurse during labor? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/min d. Late decelerations
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.
What three measures should the nurse implement to provide intrauterine resuscitation? Select the best response that indicates the priority of actions that should be taken, starting with the most important.
a.
Call the provider, reposition the mother, and perform a vaginal exam.
b.
Provide oxygen via face mask, reposition the mother, and increase IV fluid.
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.
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 resuscitationis 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 nurse caring for a woman in labor understands that maternal hypotension can result in: a. Early decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes
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.
Perinatal nurses are legally responsible for:
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
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.
As a perinatal nurse, you realize that a fetal heart rate (FHR) that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with: a. Hypotension b. Cord compression c. Maternal drug use d. Hypoxemia
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.
A new client and her partner arrive on the labor, delivery, recovery, and postpartum (LDRP) unit for the birth of their first child. You apply the electronic fetal monitor 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. Your best response is:
a.
“Don’t worry about that machine; that’s my job.”
b.
“The top line graphs the baby’s heart rate. Generally the heart rate is between 110 and 160. The 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.”
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.
A normal uterine activity (UA) pattern in labor is characterized by: 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
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.
When using intermittent auscultation (IA) for a fetal heart rate (FHR), nurses should be aware that:
a.
They 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 electronic monitoring
d.
Ultrasound can be used to find the FHR and reassure the mother if initial difficulty was a factor
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.
What is an advantage of external electronic fetal monitoring?
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.
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 positio
When assessing the relative advantages of internal electronic fetal monitoring (EFM), nurses should be cognizant of which of the following clients is not an appropriate choice for this type of fetal surveillance:
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
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.
During labor a fetus with an average fetal heart rate (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
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.
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
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.
Nurses should be aware that accelerations in the fetal heart rate (FHR):
a.
Are indications of fetal well-being when they are periodic
b.
Are greater and longer in preterm gestations
c.
Are usually seen with breech presentations when they are episodic
d.
Are a visually apparent abrupt peak
D - Acceleration of the FHR is defined as a visually apparent abrupt (only to peak 30 seconds) increase in FHR above the baseline rate.
Periodic accelerations occur with uterine contractions (UCs) and usually are seen with breech presentations. Episodic accelerations occur during fetal movement and are indications of fetal well-being.
Preterm accelerations peak at 10 beats/min above the baseline and last for at least 10 seconds.
Periodic accelerations occur with UCs and usually are seen with breech presentations. Episodic accelerations occur during fetal movement and are indications of fetal well-being.
Which deceleration of the fetal heart rate (FHR) does 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 woman’s position.
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 labor is recommended, it is not required in response to early decelerations.
Which characteristic correctly matches the type of deceleration with its likely cause?
a.
Early deceleration—umbilical cord compression
b.
Late deceleration—uteroplacental insufficiency
c.
Variable deceleration—head compression
d.
Prolonged deceleration—cause unknown
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.
The nurse caring for a woman in labor understands that prolonged decelerations:
a.
Are a continuing pattern of benign decelerations that do not require intervention
b.
Constitute a baseline change when they last longer than 5 minutes
c.
Are caused by a disruption to the fetal O2 supply
d.
Require the usual fetal monitoring by the nurse
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, the fetal cardiac tissue itself will become hypoxic, resulting in direct myocardial depression of the FHR. These can be caused by prolonged cord compression, uteroplacental insufficiency, or perhaps sustained head compression.
Prolonged decelerations lasting more 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 fetal heart rate (FHR) of at least 15 beats/min below the baseline and lasting more than 2 minutes but less than 10 minutes.
Nurses should notify the physician or nurse-midwife immediately and initiate appropriate treatment of abnormal patterns when they see a prolonged deceleration.
A nurse might 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)
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.
