When examining the fetal monitor strip after the rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:
Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.
When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:
An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.
The nurse observes the client’s amniotic fluid and decides that it appears normal, because it is:
By 36 weeks gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:
A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on the admission of this client would be:
Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.
At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:
Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.
After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed:
Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.
The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:
This is the way to determine the frequency of the contractions
The breathing technique that the mother should be instructed to use as the fetus’ head is crowning is:
Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus’ head is:
A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
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