McKinney: Chapter 17: Intrapartum Fetal Surveillance

Which maternal condition is considered a contraindication for the application of internal monitoring devices?

a. Unruptured membranes

b. Cervix is dilated to 4 cm

c. External monitors are currently being used

d. Fetus has a known heart defect

a. Unruptured membranes

To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm permits the insertion of fetal scalp electrodes and intrauterine catheter. The external monitor can be discontinued after the internal ones are applied. A compromised fetus should be monitored with the most accurate monitoring devices. p. 338

The nursing student is planning to assess a fetal heart rate. The registered nurse reminds the student to get gel. Which method of assessing the fetal heart rate is the student planning on conducting?

a. Fetoscope

b. Tocodynamometer

c. Doppler

d. Scalp electrode

c. Doppler

Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires use of a gel. p. 338

A nurse manager plans staffing for the Labor and Delivery unit. How does the available staff influence the selection of either continuous electronic or intermittent auscultation as the fetal monitoring method?

a. There must be a 1:1 nurse-to-patient ratio regardless of the method used.

b. Staffing patterns do not influence fetal monitoring choices.

c. Use of intermittent auscultation requires a lower nurse-to-patient ratio.

d. More nurses are needed when electronic fetal monitoring is used.

a. There must be a 1:1 nurse-to-patient ratio regardless of the method used.

A one-to-one ratio is needed during the second stage of labor or if a high-risk condition exists, regardless of the monitoring method used. Intermittent auscultation is more staff-intensive. Less nursing time is needed with electronic monitoring, giving the nurse more time for teaching and supporting the laboring woman. p. 336

A student nurse is placing a tocotransducer on a woman for electronic fetal monitoring. What action by the student indicates to the registered nurse that the student understands the procedure?

a. Places the tocotransducer over the uterine fundus

b. Prepares sterile field for fetal scalp electrode placement

c. Positions the tocotransducer on the woman's upper arm

d. Attaches the tocotransducer to the woman's lower abdomen

a. Places the tocotransducer over the uterine fundus

The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. No sterile field is needed. The tocotransducer is not placed on the upper arm or lower abdomen. p.338

A student nurse is preparing to administer misoprostol (Cytotec). What action by the student seen by the registered nurse demonstrates adequate knowledge about this medication?

a. Assesses maternal blood pressure 30 minutes after administration

b. Assesses fetal heart tones prior to administering the medication

c. Documents the drug administration in the woman's chart

d. Takes and records an apical pulse for 1 minute prior to administration

b. Assesses fetal heart tones prior to administering the medication

Fetal heart tones should be assessed prior to giving cervical ripening agents such as misoprostol. It is not necessary to assess maternal blood pressure afterward or an apical pulse prior to administering the medication. Documentation of all medications is a legal requirement but is not related specifically to this drug. Box 17.2

A woman has a history of hypertension during pregnancy. What method of intrapartum fetal monitoring does the nurse initiate?

a. Continuous auscultation with a fetoscope

b. Continuous electronic fetal monitoring

c. Intermittent assessment with a Doppler transducer

d. Intermittent electronic fetal monitoring for 15 minutes each hour

b. Continuous electronic fetal monitoring

Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition. It is not practical to provide continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is at high risk for complications. p. 333

Why is continuous electronic fetal monitoring usually used when oxytocin is administered?

a. The mother may become hypotensive.

b. Uteroplacental exchange may be compromised.

c. Maternal fluid volume deficit may occur.

d. Fetal chemoreceptors are stimulated.

b. Uteroplacental exchange may be compromised.

The uterus may contract more firmly, and the resting tone may be increased with oxytocin use. This response reduces entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk. Oxytocin affects the uterine muscles. p.333

The nurse-midwife is concerned that a woman's uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. On the basis of this information, the nurse should obtain a(n)

a. tocotransducer.

b. scalp electrode.

c. intrauterine pressure catheter.

d. Doppler transducer.

c. intrauterine pressure catheter.

An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this not be accurate with obesity. A scalp electrode measures the fetal heart rate (FHR). A Doppler auscultates the FHR. p.339

In which situation is a baseline fetal heart rate of 160 to 170 beats per minute considered a normal finding?

a. The fetus is at 28 weeks of gestation.

b. The mother has been given an epidural block.

c. The mother has a history of fast labors.

d. The mother has mild preeclampsia but is not in labor.

a. The fetus is at 28 weeks of gestation.

The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Any change in the FHR with an epidural is not considered an expected outcome. Fast labors should not alter the FHR normally. Preeclampsia should not cause a normal elevation of the FHR. p. 340

When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?

a. Increase in baseline variability

b. Nonperiodic accelerations

c. Early decelerations

d. Variable decelerations

d. Variable decelerations

When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. This is not an expected occurrence after the rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Early declarations are considered reassuring; they are not a concern after rupture of membranes. p. 343

The fetal heart rate baseline increases 15 beats per minute after vibroacoustic stimulation. What action by the nurse is most appropriate?

a. Reassure the family the finding is normal.

b. Prepare to assist with obtaining cord blood gases.

c. Position the woman on her left side.

d. Administer oxygen at 4 L via nasal cannula.

a. Reassure the family the finding is normal.

The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic stimulation with a temporary increase in the fetal heart rate (FHR) over baseline of 15 bpm for 15 seconds or more. The nurse reassures the family that this finding is normal. The other actions are not warranted. p.346

The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?

a. Lower the head of the bed.

b. Place the mother in a Trendelenburg position.

c. Change her position to the right side.

d. Place a wedge under the left hip.

c. Change her position to the right side.

Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta. The other actions are not warranted. p. 347

The nurse notes a pattern of late decelerations on the fetal monitor. The most appropriate action is to

a. continue observation of this reassuring pattern.

b. notify the physician or nurse-midwife.

c. give the woman oxygen by face mask.

d. place the woman in a Trendelenburg position.

c. give the woman oxygen by face mask.

Late decelerations are associated with reduced placental perfusion. Giving the laboring woman oxygen increases the oxygen saturation in her blood, making more oxygen available to the fetus. This is not a reassuring pattern; interventions are needed. Nursing interventions should be initiated before notifying the health care provider. The Trendelenburg position will not increase the placental perfusion. p. 342 -p. 344 -Safety Alert Box

The nurse explains to the student that increasing the infusion rate of non-additive intravenous fluids can increase fetal oxygenation primarily by

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.

d. expanding maternal blood volume.

Filling the mother's vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most intravenous fluids for laboring women are isotonic and do not improve hypoglycemia. Oxygen-carrying capacity is increased by adding more red blood cells. p. 344-Safety Alert Box

Which nursing action is correct when initiating electronic fetal monitoring?

a. Lubricate the tocotransducer with an ultrasound gel.

b. Inform the patient that she should remain in the semi-Fowler's position.

c. Securely apply the tocotransducer with a strap or belt.

d. Determine the position of the fetus before attaching the electrode.

c. Securely apply the tocotransducer with a strap or belt.

The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately. The tocotransducer does not need gel to operate appropriately. The patient should be encouraged to move around during labor. The tocotransducer should be placed at the fundal area of the uterus. p. 338- Procedure Box

Which statement correctly describes the nurse's responsibility related to electronic monitoring?

a. Teach the woman and her support person about the monitoring equipment, and discuss any questions they have.

b. Report abnormal findings to the physician before initiating corrective actions.

c. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place.

d. Document the frequency, duration, and intensity of contractions measured by the external device.

a. Teach the woman and her support person about the monitoring equipment, and discuss any questions they have.

Teaching is an essential part of the nurse's role. Corrective actions should be initiated first in order to correct abnormal findings as quickly as possible. The support person should be encouraged to assist with the comfort measures. Electronic monitoring will record the contractions and FHR response. p.347

The precepting nurse explains to the newly hired nurse that when using IA for FHR which situation is unit protocol?

a. The nurses 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 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 fetal heartbeat and reassure the mother if initial difficulty was a factor.

d. Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.

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, auscultation requires a nurse-to-patient ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate. Electronic monitoring is not needed at this point. p. 335

The new nurse learns that 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. A periodic fetal sleep state

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. The other conditions would be considered conducive to abnormal variability. p. 340

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 FHR.

d. to elicit an acceleration in the FHR.

The scalp can be stimulated using digital pressure during a vaginal examination, which should cause an increase in FHR. Stimulating the fetal scalp is not part of blood sampling, assessing the response to tocolysis, or in preparation for oxygen saturation monitoring. p. 345

In the low-risk patient assessments for variability and periodic changes if using the fetal monitor should be done how often?

a. Every 15 to 30 minutes

b. Every 5 to 15 minutes

c. Every 30 to 60 minutes

d. Only before and after ambulation

a. Every 15 to 30 minutes

During the active first stage of labor, FHR should be assessed every 15 to 30 minutes just after a contraction. p. 385-Box 17.1

A new nurse notes a fetal heart rate pattern of late deceleration with minimal variability in a laboring woman with vaginal bleeding. Which action by the new nurse warrants intervention by the charge nurse?

a. Assesses maternal blood pressure

b. Assesses for a prolapsed cord

c. Prepares to administer terbutaline

d. Discontinues oxytocin

b. Assesses for a prolapsed cord

Assessing for a prolapsed cord requires a vaginal examination, which is contraindicated when the woman has active vaginal bleeding. The other actions are appropriate. p. 344- Safety Alert Box

A Labor and Delivery nurse knows that four of the five fetal factors that interact to regulate the heart rate are which of the following? (Select all that apply.) FOUR answers

a. Uterine activity

b. Autonomic nervous system

c. Baroreceptors

d. Chemoreceptors

e. Adrenal glands

b. Autonomic nervous system

c. Baroreceptors

d. Chemoreceptors

e. Adrenal glands

The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, while parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and the aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing an acceleration in FHR. Uterine activity is a maternal factor. p. 333

The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alterations? (Select all that apply.) TWO answers

a. Spontaneous fetal movement

b. Compression of the fetal head

c. Placental abruption

d. Cord around the baby's neck

e. Maternal supine hypotension

c. Placental abruption

e. Maternal supine hypotension

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 placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the cord is around the baby's neck, arm, leg or other body part, a short cord, a knot in the cord, or a prolapsed cord. Table 17.1

A new nurse to Labor and Delivery learns about the three categories of fetal heart rate patterns. Which characteristics of the fetal heart belong in Category III? (Select all that apply.) FOUR answers

a. Baseline rate of 110 to 160 bpm

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

b. Tachycardia

d. Variable decelerations with other characteristics such as shoulders or overshoots

e. Absent baseline variability with recurrent variable decelerations

f. Bradycardia

These characteristics are all considered non-reassuring or abnormal and belong in Category III. A fetal heart rate of 110 to 160 bpm is considered normal and belongs in Category I. Absent baseline variability not accompanied by recurrent decelerations is a Category II characteristic. p. 344

Which of the following factors place the intrapartum woman at risk for complications during labor and delivery? (Select all that apply.) THREE answers

a. Prolonged rupture of membranes

b. Chorioamnionitis

c. Fever

d. History of stillbirth

e. Drug use

a. Prolonged rupture of membranes

b. Chorioamnionitis

c. Fever

Prolonged rupture of membranes, Chorioamnionitis, and fever are specific to the intrapartum period. Stillbirths and drug use are problems found in the antepartum period. Box 17.1

What action by the nurse is most appropriate?
A. Apply oxygen via face mask, and position the woman on her left side.
B. Document the findings in the chart along with maternal vital signs.
C. Prepare to start an infusion of oxytocin per unit protocol.
D. Decrease the rate of the woman's IV maintenance fluids.

ANS: A. Apply oxygen via face mask, and position the woman on her left side.

This tracing shows a late deceleration. The mother should be given oxygen and positioned on
her left side. The findings should be documented, but only after interventions have occurred.
Oxytocin would increase uterine activity (and increase stress on the fetus) so should not be
started, or if already running, discontinued. IV fluids should be increased.
PTS: 1 DIF: Cognitive Level: Analysis REF: Figure 17.10
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse assesses the fetal monitor and sees the following strip. What action by the nurse is
most appropriate?
a. Administer oxygen by nasal cannula.
b. Reposition the woman.
c. Apply a fetal scalp electrode.
d. Record this reassuring pattern.

ANS: D. Record this reassuring pattern.

This is a reassuring pattern and no intervention is necessary beyond documentation.
PTS: 1 DIF: Cognitive Level: Analysis/Analyzing
REF: Figure 17.6 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance