NCLEX FETAL ASSESSMENT

NCLEX FETAL ASSESSMENT

DURING LABOR

Fetal tachycardia is most common during:

• Maternal fever
• Umbilical cord prolapse
• Regional anesthesia
• MgSO4 administration

A

• Maternal fever

Correct: Fetal tachycardia can be considered an early sign of fetal hypoxemia and can also result from maternal or fetal infection.

• Umbilical cord prolapse

Incorrect: This situation most likely would result in fetal bradycardia, not tachycardia.

• Regional anesthesia

Incorrect: This situation most likely would result in fetal bradycardia, not tachycardia.

• MgSO4 administration

Incorrect: This situation most likely would result in fetal bradycardia, not tachycardia.

• 505

Fetal bradycardia is most common during:

• Intraamniotic infection
• Fetal anemia
• Prolonged umbilical cord compression
• Tocolytic treatment using ritodrine

C

A. Incorrect: This circumstance most likely would result in fetal tachycardia.

B. Incorrect: This circumstance most likely would result in fetal tachycardia.

• Correct: Fetal bradycardia can be considered a later sign of fetal hypoxia and is

known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension.

D. Incorrect: This circumstance most likely would result in fetal tachycardia.

• 503

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:

• Change the woman's position
• Notify the care provider

• Assist with amnioinfusion
• Insert a scalp electrode

A

A. Correct: Late decelerations may be caused by maternal supine hypotension

syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava.

• Incorrect: If the fetus does not respond to primary nursing interventions for late

decelerations, the nurse would continue with subsequent intrauterine resuscitation measures, including notifying the care provider.

• Incorrect: 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 reveals variable deceleration.

• Incorrect: A fetal scalp electrode would provide accurate data for evaluating the well-

being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurse's first priority.

• 507

The nurse caring for the laboring woman should understand that early

decelerations are caused by:

• Altered fetal cerebral blood flow
• Umbilical cord compression
• Uteroplacental insufficiency
• Spontaneous rupture of membranes

A

• Correct: Early decelerations are the fetus's response to fetal head compression.
• Incorrect: Variable decelerations are associated with umbilical cord compression.
• Incorrect: Late decelerations are associated with uteroplacental insufficiency.
• Incorrect: Spontaneous rupture of membranes has no bearing on the FHR unless the

umbilical cord prolapses, which would result in variable or prolonged bradycardia.

• 507

The nurse providing care for the laboring woman should understand that

accelerations with fetal movement:

• Are reassuring
• Are caused by umbilical cord compression
• Warrant close observation
• Are caused by uteroplacental insufficiency

A

• Correct: Episodic accelerations in the FHR occur during fetal movement and are

indications of fetal well-being.

• Incorrect: Umbilical cord compression results in variable decelerations in the FHR.

• Incorrect: Accelerations in the FHR are an indication of fetal well-being and do not

warrant close observation.

• Incorrect: Uteroplacental insufficiency would result in late decelerations in the FHR.

• 504