18 Fetal Assessment (Labor)
What is the most likely cause for early decelerations in the fetal heart rate
(FHR) pattern?
a. Altered fetal cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Spontaneous rupture of membranes - correct answer ✔ANS: 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.
2. Which clinical finding or intervention might be considered the rationale for
fetal tachycardia to occur?
a. Maternal fever
b. Umbilical cord prolapse
c. Regional anesthesia
d. Magnesium sulfate administration - correct answer ✔ANS: A
Fetal tachycardia can be considered an early sign of fetal hypoxemia and may
also result from maternal or fetal infection. Umbilical cord prolapse,Regional
,anesthesia, and 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 - correct answer ✔ANS: 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. If the fetus does not
respond to primary nursing interventions for late decelerations, the nurse
should continue with subsequent intrauterine resuscitation measures,
including notifying the health care provider. An amnioinfusion may be used to
relieve pressure on an umbilical cord that has not prolapsed. The fetal heart
rate pattern associated with this situation most likely will reveal variable
decelerations.
A fetal scalp electrode provides accurate data for evaluating the well-being of
the fetus; however, this is not a nursing intervention that will alleviate late
decelerations, nor is it the nurse's first priority.
What is the most likely cause for variable FHR decelerations?
a. Altered fetal cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
, d. Fetal hypoxemia - correct answer ✔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 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.
5. The nurse providing care for a high-risk laboring woman is alert for late
FHR decelerations. Which clinical finding might be the cause for these late
decelerations?
a. Altered cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Meconium fluid - correct answer ✔ANS: 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.
6. Which alteration in the FHR pattern would indicate the potential need for an
amnioinfusion?
a. Variable decelerations
b. Late decelerations
What is the most likely cause for early decelerations in the fetal heart rate
(FHR) pattern?
a. Altered fetal cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Spontaneous rupture of membranes - correct answer ✔ANS: 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.
2. Which clinical finding or intervention might be considered the rationale for
fetal tachycardia to occur?
a. Maternal fever
b. Umbilical cord prolapse
c. Regional anesthesia
d. Magnesium sulfate administration - correct answer ✔ANS: A
Fetal tachycardia can be considered an early sign of fetal hypoxemia and may
also result from maternal or fetal infection. Umbilical cord prolapse,Regional
,anesthesia, and 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 - correct answer ✔ANS: 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. If the fetus does not
respond to primary nursing interventions for late decelerations, the nurse
should continue with subsequent intrauterine resuscitation measures,
including notifying the health care provider. An amnioinfusion may be used to
relieve pressure on an umbilical cord that has not prolapsed. The fetal heart
rate pattern associated with this situation most likely will reveal variable
decelerations.
A fetal scalp electrode provides accurate data for evaluating the well-being of
the fetus; however, this is not a nursing intervention that will alleviate late
decelerations, nor is it the nurse's first priority.
What is the most likely cause for variable FHR decelerations?
a. Altered fetal cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
, d. Fetal hypoxemia - correct answer ✔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 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.
5. The nurse providing care for a high-risk laboring woman is alert for late
FHR decelerations. Which clinical finding might be the cause for these late
decelerations?
a. Altered cerebral blood flow
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Meconium fluid - correct answer ✔ANS: 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.
6. Which alteration in the FHR pattern would indicate the potential need for an
amnioinfusion?
a. Variable decelerations
b. Late decelerations
