N306 OB QUIZ 2 Stages of Labor and
FHR assessment
Pt education for amnioinfusion
- EXPLAIN:
fluid is infuse via IUPC to cervix to the uterus
room temp NS or Lactated ringers solutions
fluid leaking from vagina is normal & nurse continue to monitor
Priority intervention for fetus experience prolonged decelerations
- change maternal position
Fetus is displaying minimal variability is the nurse priority, why?
- bc mom exhibiting tachysystole (8 contractions in 10 mins) requires intervention to
imporve fetus Oxygenation
How do the nurse know that there is a change in FHR baseline?
- FHR increase or decrease for > 10 mins
ex. FHR decrease from 145 to 115 for a period of 15 mins
During leopold's maneuver, the nurse palpates the fetus head at the fundus and the
presenting part is not engage, this mean that?
- fetus is breech and the nurse should put the dopper monitor at the upper fundal area
of the mom
Nurse action for variable deceleration with 2 contraction
- change mom position to lateral side lying
Minimal Variability requires immedicate action from the nurse, why?
- indicates the fetus is hypoxia or acidois due to low O2 supply when contraction occur
closer together (tachysytole)
Category I tracing documentation includes
- FHR baseline 110-160 bpm
Baseline variability moderate
Acceleration present or absent
Early deceleration present or absent
late or varible deceleration absent
Category III tracing documentation includes
- All have Normal baseline 110-160 bpm
Absent variability with any of the ff:
recurrent late deceleration
reccurrent variable deceleration
, Bradycardia < 100bpm
Sinosoidal pattern
requires 50% of each FHR pattern
Ocytocin is infuse that leads to the FHR tracing of category 3, what is the priority
action?
- discontnue the oxytocin to decrease to reduce uterine activity, allow perfusion, O2 to
the fetus
What can cause FHR to increase? What is the nurse priority action?
- Cause by maternal fever and tachycardia increases FHR (ex. FHR 180 w/ no
accelerations)
Nurse should assess mom vital sign
What is the priority nurase action if FHR is 80's bpm?
- FHR is in 80's mean bradycardia (category 111 tracing)
The nurse should:
1. confirm maternal HR to FHR
2. Verify fetal movement
3. Notify provider asap to order ultrasound
How to respond id the fetus is demostrating minimal varibility or absent variability?
- 1) change maternal position
2)Perform vibroacoustic stimulation to asses fetal reponse
3) Give IV bolus > 500 mi LR
4. Discontinue oxytocin
5. Oxygen 10 L, nonbreather facemask
When FHR is in catergoy 3 (late decelerations), the priority nurse action are IUR?
- IUR (intrauterine resuscitation):
change mom position to lateral side lying
give O2 10 L via nonbreather face mask
Give IV bolus > 500 ml to increase perfusion
discontinue oxytocin (can cause contraction tachysystole)
Notify provider
(does amnioinfusion requires doctors order?
In preterm labor ex. 26 weeks gestation, what are the unexpected finding & needs
priority actions?
- FHR over 160 bpm (tachycardia)
late deceleration
contractions 2-4 mins (in active phase of labor)
(we want to stop the labor, its not time yet)
FHR assessment
Pt education for amnioinfusion
- EXPLAIN:
fluid is infuse via IUPC to cervix to the uterus
room temp NS or Lactated ringers solutions
fluid leaking from vagina is normal & nurse continue to monitor
Priority intervention for fetus experience prolonged decelerations
- change maternal position
Fetus is displaying minimal variability is the nurse priority, why?
- bc mom exhibiting tachysystole (8 contractions in 10 mins) requires intervention to
imporve fetus Oxygenation
How do the nurse know that there is a change in FHR baseline?
- FHR increase or decrease for > 10 mins
ex. FHR decrease from 145 to 115 for a period of 15 mins
During leopold's maneuver, the nurse palpates the fetus head at the fundus and the
presenting part is not engage, this mean that?
- fetus is breech and the nurse should put the dopper monitor at the upper fundal area
of the mom
Nurse action for variable deceleration with 2 contraction
- change mom position to lateral side lying
Minimal Variability requires immedicate action from the nurse, why?
- indicates the fetus is hypoxia or acidois due to low O2 supply when contraction occur
closer together (tachysytole)
Category I tracing documentation includes
- FHR baseline 110-160 bpm
Baseline variability moderate
Acceleration present or absent
Early deceleration present or absent
late or varible deceleration absent
Category III tracing documentation includes
- All have Normal baseline 110-160 bpm
Absent variability with any of the ff:
recurrent late deceleration
reccurrent variable deceleration
, Bradycardia < 100bpm
Sinosoidal pattern
requires 50% of each FHR pattern
Ocytocin is infuse that leads to the FHR tracing of category 3, what is the priority
action?
- discontnue the oxytocin to decrease to reduce uterine activity, allow perfusion, O2 to
the fetus
What can cause FHR to increase? What is the nurse priority action?
- Cause by maternal fever and tachycardia increases FHR (ex. FHR 180 w/ no
accelerations)
Nurse should assess mom vital sign
What is the priority nurase action if FHR is 80's bpm?
- FHR is in 80's mean bradycardia (category 111 tracing)
The nurse should:
1. confirm maternal HR to FHR
2. Verify fetal movement
3. Notify provider asap to order ultrasound
How to respond id the fetus is demostrating minimal varibility or absent variability?
- 1) change maternal position
2)Perform vibroacoustic stimulation to asses fetal reponse
3) Give IV bolus > 500 mi LR
4. Discontinue oxytocin
5. Oxygen 10 L, nonbreather facemask
When FHR is in catergoy 3 (late decelerations), the priority nurse action are IUR?
- IUR (intrauterine resuscitation):
change mom position to lateral side lying
give O2 10 L via nonbreather face mask
Give IV bolus > 500 ml to increase perfusion
discontinue oxytocin (can cause contraction tachysystole)
Notify provider
(does amnioinfusion requires doctors order?
In preterm labor ex. 26 weeks gestation, what are the unexpected finding & needs
priority actions?
- FHR over 160 bpm (tachycardia)
late deceleration
contractions 2-4 mins (in active phase of labor)
(we want to stop the labor, its not time yet)
