Summary
Summary Nurs 431 Exam 2 Study Guide
- Course
- Nurs 431
- Institution
- Holy Family University
This is a comprehensive and detailed study guide on Exam 2 for Nurs 431. *Essential Study Material!!
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Page |1Fetal Monitoring Basics/Assessment
Auscultation and Palpation
So, when we talk about fetal assessment, the first thing we talk about is assessing the fetal heart rate and with this comes
auscultation and palpation. In order to auscultate, we have to palpate 1st to see where the baby is in relationship to the
mom’s uterus. So, what the healthcare provider is going to do is use the Leopold's maneuver to make sure that the baby is
in the correct position in terms of where they're going to place the Doppler. Now when auscultating you can also use
something called a fetus scoop which looks just like a regular stethoscope, only the end of it is a little bit longer and the
sound can be heard more easily. Plus, remember when you're asked auscultating for a fetal heart rate, a normal newborn
fetal heart rate is going to be 110 to 160.
External Vs. Internal
Electronic Fetal Monitoring: External
Continuous external fetal monitoring is accomplished by securing an
ultrasound transducer over the client’s abdomen, which records the FHR pattern
(bottom), and a tocotransducer (top) on the fundus that records the uterine
contractions.
☆ Electronic Fetal Monitoring: Internal ☆
Continuous internal fetal monitoring with a scalp electrode is performed by
attaching a small spiral electrode to the presenting part of the fetus to monitor
the FHR. The electrode wires are then attached to a leg plate that is placed on
the client’s thigh and then attached to the fetal monitor. It can also be used in
conjunction with an intrauterine pressure catheter (IUPC), which is a solid or
fluid-filled transducer placed inside the client’s uterine cavity to monitor the
frequency, duration, and intensity of contractions.
ADVANTAGES DISADVANTAGES
• Early detection of abnormal FHR patterns • Membranes must have ruptured to use internal
suggestive of fetal distress. monitoring.
• Accurate assessment of FHR variability. • Cervix must be adequately dilated to a minimum of 2 to
• Accurate measurement of uterine contraction 3 cm.
intensity. • Presenting part must have descended to place electrode.
• Allows greater maternal freedom of movement • Potential risk of injury to fetus if electrode is not properly
because tracing is not affected by fetal activity, applied.
maternal position changes, or obesity. • A provider, nurse practitioner/midwife, or specially
trained registered nurse must perform this procedure.
• Potential risk of infection to the client and the fetus.
When to use internal monitoring
• If you have a patient that say the external monitoring is not working right because the contractions aren't being picked up and
patient is feeling the contractions, but no matter where you put the monitor, it's still won’t pick up the contractions
, Page |2
• The contractions are showing something that might indicate us to do internal monitoring because the internal monitor is going
to be more accurate than the external
• The important thing to know about internal monitoring is you can see there's a pressure cap that is inserted into the
vaginal area, into the cervix, up into the uterus. The only way that you can do internal monitoring with an IUPC or the
fetal monitoring that measures the baby's heart rate is if the mom's water has broken, and if she's at least one to two
centimeters dilated where they can actually insert this in into the vaginal canal.
• So, this also monitors in uterine contractions and what happens is once it's put along the side of the uterus, every time there's a
contraction, it presses on it and gives a more accurate reading of how strong this contraction is going to be. Where there is the
little red and blue line wires that attach to the baby's head, what that is, is that's internal electronic fetal monitoring that
measures the baby's heart rate. So, what happens is there's a little Corkscrew like thing like a metal device that actually
corkscrews into the top of the scalp of the baby and what that does is it measures the beat-to-beat variability of the baby's
heart rate.
☆ What are we looking for? ☆
• Baseline: 110 – 160 bpm
• Fetal heart rate baseline variability is described as fluctuations in the FHR
baseline that are irregular in frequency and amplitude. Expected variability
should be moderate variability. Classification of variability is as follows:
• Variability: absent (considered nonreassuring – stays at 110 w/nonvariation),
minimal (detectable but equal to or less than 5/min – 110 to 114, not a big
increase/decrease in FHR), moderate (6 to 25/min – good, baby is active, FHR
increase and decreases), or marked (greater than 25/min – too much activity, FHR
goes up/down for an extended period of time, must monitor to see if the baby is stressed)
• Deviations from the baseline: Changes in fetal heart rate patterns are categorized as episodic or periodic changes.
Episodic changes are not associated with uterine contractions, and periodic changes occur with uterine
contractions. These changes include accelerations and decelerations.
o Accelerations: we want to see the baby’s HR accelerate up to 15 bpm lasting at least 15 seconds, baby
is healthy in the mom’s uterus
o Decelerations: baby’ HR is going down, if not necessarily a bad thing, particularly if see decelerations in
the early stages of labor
a. Early: mimic contraction patterns (they happen during contractions), the FHR will slightly go
down during the contraction and go back up before the contraction is over
b. Late: concerning – uteroplacental insufficiency when the placenta does not work properly.
You're going to see the baby's heart rate go down mid contraction and actually stays down until
after the contraction is over, and that means that that baby was stressed out during that
contraction.
c. Variable: the heart rate goes down for maybe like 10 or 20 seconds and then goes back up to
baseline and it looks like a V on the fetal monitor strip. Those are usually the result of cord
compression whether the cords is wrapped around the neck or wrapped around another body
part.
Fetal Monitor Strips (On the Exam)
Each line is 10 secs, each dark line is 1 min. Top strip is where
you will see the FHR and on the Bottom strip is where you will
see mom’s contractions
Baseline 110-160
T
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I
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Variability (Fetal Movement)
• Single best indicator of fetal well-being
• Absent (no activity at all)
• Minimal: <5 bpm amplitude (sleeping, bradycardia)
• Moderate (only normal one) 6-25 bpm
• Marked: > 25 bpm amplitude (baby is in distressed, tachycardia)
Accelerations: always good, shows fetal movement and well-Being
check baseline which in this picture it is at 145
(normal HR), you want to see 15 beats above
baseline, for 15 seconds, which here it shows
acceleration at 155 – 160, 1st one shows 15 secs, 2nd
one shows, 30 secs, 3rd one shows, 20 secs. This
shows a reactive nonstress test, meaning the baby is
not stress and reactive
Decelerations
Types of decelerations
• Early: good contraction and fetal HR: result from
head compression (baby is descending down the
birth canal)
• Late: happens midway and doesn’t come back up
after the contraction. uteroplacental insufficiency -
Turn mom to the side
• Variable: occurs with or without contractions. This
is due to cord compression
Read the picture
Early Decelerations: Good Late Decelerations: BAD
, Page |4
Slowing of FHR at the start of contraction with Slowing of FHR after contraction has started (mid
return of FHR to baseline at end of contraction cx) with return of FHR to baseline well after
contraction has ended
Variable Decelerations: Varies
Variable deceleration of FHR
Transitory, abrupt slowing of FHR 15/min or
more below baseline for at least 15 seconds, variable in duration, intensity, and timing in relation to uterine contraction
CAUSES/COMPLICATIONS NURSING INTERVENTIONS
● Umbilical cord compression ● Reposition client from side to side or into knee-chest.
● Short cord ● Discontinue oxytocin if being infused.
● Prolapsed cord ● Administer oxygen by mask at 8 to 10 L/min via
● Nuchal cord (around fetal neck) nonrebreather face mask.
● Perform or assist with a vaginal examination.
● Assist with an amnioinfusion if prescribed.
Fetal tachycardia: usually caused by maternal infection FHR >160/min for 10 min or more
Maternal use of cocaine or methamphetamines, Maternal dehydration, Maternal or fetal infection, Maternal
hyperthyroidism. Take mom’s vitals every hr.
NURSING INTERVENTIONS
- Administer prescribed antipyretics for maternal fever if
present.
- Administer oxygen by mask at 10 L/min via nonrebreather
face mask.
- Administer IV fluid bolus.
Fetal Bradycardia: FHT<110 bpm 10 min or more
If mom get hypotensive or had an epidural, the baby HR
goes bradycardic. Turn mom to the side and if that doesn’t work, turn mom to the other side and if that doesn’t
work, place mom in a knee-chest position
NURSING INTERVENTIONS
- Discontinue oxytocin if administered.
- Assist the client in a side-lying position.
- Administer oxygen by mask at 10 L/min via
nonrebreather face mask.
- Insert an IV catheter if one is not in place and administer
maintenance IV fluids.
- Administer a tocolytic medication.
- Notify the provider.
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