NCLEX FETAL ASSESSMENT

NCLEX FETAL ASSESSMENT

DURING LABOR

Where should fetal heart tones be assessed in a Vertex Presentation ?In a vertex presentation fetal heart tones should be assessed below the clients umbilicus in either the right or left lower quadrant What is a Vertex Presentation is the medical term for crown of the head, Vertex presentation indicates that the head of the baby is presenting towards the cervix How should a patient be prepared for Leopold Maneuvers?Ask the patient to empty their bladder before the procedure.Place the client in a supine position with a pillow below the head and have both knees slightly flexed.Place a small rolled towel under the clients right or left hip to displace the uterus off the major blood vessels and avoid supine hypotensive syndrome.Where should the heart tones should be assessed in a Breech presentation?In a Breech presentation fetal heart tones should be assessed above the clients umbilicus in either the right or left upper quadrant of the abdomen Leopold maneuvers is a part of the fetal assessment during labor, please define Leopold maneuvers consist in performing external palpation of the maternal uterus to

determine:

Presenting part.Fetal lie.and fetal attitude.Also the degree of descent of the presenting part into the pelvis.Location of the fetus back to assess for fetal heart tones.The location of the fetus back during fetal assessment during labor to assess for fetal heart tones, fetal lie and presenting part is called ...Leopold Maneuvers How can you determine the degree of descent of the presenting part into the pelvis?Leopold Maneuvers During the fetal assessment during labor what will determine the presenting part, fetal lie, and fetal attitude?Leopold Maneuvers During Leopold Maneuver, how do you identify the fetal lie (longitudinal or transverse) and presenting part (cephalic or breech)?You identify the fetal part occupying the fundus. The head should feel round, firm, and move freely while breech should feel irregular and soft.During Leopold Maneuver, how do you validate the presenting part?Locate and palpate the smooth contour of the fetal back using the palm of one hand and the irregular small part of the hands, feet and elbows using the palm of the other hand.During Leopold Maneuver, how do you identify the descent of the presenting part into the pelvis?

Determine the part that is presenting over the true pelvis inlet by gently grasping the lower segment of the uterus between the thumb and fingers. if the head is presenting and not engaged, determine whether the head is flexed or extended.During Leopold Maneuver, how do you identify the fetal attitude?Face the client's feet and outline the fetal head using the palmar surface of the fingertips on both hands to palpate the cephalic prominence. If the cephalic prominence is on the same side as the smalls parts, the head is flexed with vertex presentation.If the cephalic prominence is on the same side as the back the head is extended with a face presentation.What interventions should the nurse implement during Leopold Maneuvers?Auscultate the FHR post-maneuvers to assess the fetal tolerance of the procedure.Document the findings from the maneuvers.How would you define Intermittent auscultation and uterine contraction palpation?Intermittent auscultation of the FHR us a low-technology method that can be performed during labor using a hand-held Doppler ultrasounds device, ultrasound stethoscope, or fetoscope to assess FHR. Also in conjunction palpation of the contractions at the fundus for frequency, intensity, duration, and resting tone is used to evaluate fetal well-being.What happens with uterine contractions during labor?During labor uterine contractions compress the uteroplacental arteries, temporarily stopping maternal blood flow into the uterus and intervillous spaces of the placenta, decreasing fetal circulation and oxygenation.When does the circulation to the uterus and placenta resumes?Circulation of the uterus and placenta will resume during uterine relaxation between the contractions.For low risk labor and delivery Intermittent auscultation and uterine contraction palpation would allow?This procedure will allow for low risk labor and delivery the client the freedom of movement and can be done at home or at a birthing center.What would be the guidelines for intermittent auscultation or continuous electronic fetal monitoring?

During latent phase: every 30 to 60 minutes

During active phase: every 15 to 30 minutes

During the second stage: every 5 to 15 minutes

What would be the considerations a nurse should do during a fetal assessment during labor?Based on findings obtained using Leopold Maneuvers, auscultate the FJR using a listening device.Palpate the uterine fundus to assess uterine activity.Count fetal FHR for 30 to 60 seconds between contractions to determine a baseline rate.Auscultate FHR before, during, and after a contraction to determine FHR in response to the contractions.What would be considered a normal reassuring FHR?110 to 160 beats per minute with increases and decreases from baseline.When a FHR would be considered tachycardia?

When is greater than 160/min for 10 minutes or longer.When a FHR would be considered bradycardia?When is less than 110/min for 10 minutes or longer.Define Continuous electronic fetal monitoring?Continuous external fetal monitoring is accomplished by securing an ultrasound transducer over the client's abdomen, which records the FHR pattern, and a tocotransducer on the fundus that records the uterine contractions What would be advantages of Continuous electronic fetal monitoring?Monitoring is noninvasive and reduces the risk for infection.Membranes do not have to be ruptured.Cervix does not have to be dilated.Placement of the transducers can be performed by the nurse.Provides permanent record of the FHR and uterine contraction tracings.What would be the disadvantages of Continuous electronic fetal monitoring?Contraction intensity is not measure.Movement of the client requires frequent repositioning of transducers.Quality of recording is affected by client obesity and fetal position.When would Continuous electronic fetal monitoring be indicated?Multiple gestations.Oxytocin infusion (augmentation or induction of labor) Placenta previa.Fetal bradycardia Maternal complications (gestational diabetes, gestational hypertension, kidney disease).Intrauterine growth restriction.Post date gestation.Active labor.Meconium stained amniotic fluid.Abruptio placenta (suspected or actual) Abnormal nonstress test or contraction stress test Abnormal uterine contractions.Fetal distress.What is considered a normal fetal heart rate baseline?A normal fetal heart rate baseline at term is 110 to 160/min excluding accelerations, decelerations adn periods of marked variability within 10 minute window.At least 2 minutes of baseline segments in a 10 minute window should be present and a single number should be documented instead of a baseline range.How is fetal heart rate baseline variability described?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.

What are the fetal heart rate baseline variability classifications?Absent or undetectable variability (considered nonreassuring) Minimal variability (detectable but equal to or less than 5/min) Moderate variability (6 to 25/min) Marked variability (greater than 25/min) How are the fetal heart rate PATTERNS categorized?

Episodic or periodic.Episodic changes are not associated with uterine contractions and periodic changes occur with uterine contractions. These changes include accelerations and decelerations.

Each uterine contraction is comprised of the following:

Increment : the beginning of the contraction as intensity is increasing.

Acme: the peak intensity of the contraction.

Decrement: the decline of the contraction intensity as the contraction is ending.Nonreassuring FHR patterns are associated with what?Feal hypoxia What would be considered as nonreassuring FHR patterns?Fetal bradycardia.Fetal tachycardia.Absence of FHR variability.Late decelerations.Variable decelerations.In a FHR pattern accelerations would be considered?Variable transitory increase in the FHR above the baseline.Causes of FHR accelerations?Healthy fetal/placental exchange.Intact fetal central nervous system (CNS) response to fetal movement.Vaginal exam.Uterine contractions.Fetal scalp stimulation.Vibroacustic stimulation.Fundal pressure.What are nursing interventions for FHR accelerations?Be reassuring.No interventions are required.Indicative reactive nonstress test.What are causes/complications for fetal bradycardia?Uteroplacental inssufficinecy.Umbilical cord prolapse.Maternal hypotension. Prolonged umbilical cord compression.Fetal congenital heart block.Anesthetic medications.Viral infection.Maternal hypoglycemia.Fetal heart failure.Maternal hypothermia.What would be the nursing interventions ion fetal bradycardia?Discontinue oxytocin if being administered.Assist the client to a side lying position.Administer oxygen by mask at 10L/min via non rebreather mask.Insert an IV catheter if one not in place and administer maintenance IV fluids.Administer a tocolytic medication.Notify the provider.