The nurse decides to apply an external monitor because the membranes are intact. The test is used to determine if a fetus is at risk for intrauterine death or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal hypoxemia. The frequency of use is based on clinical judgment, but is common because it is non-invasive and presents a low maternal and fetal risk; however, the test does not hold predictive value and only indicates fetal hypoxia at time of the test.

Option A: The cervix is dilated enough to use an internal monitor, if necessary. Fetal heart rate is monitored using the Doppler ultrasound transducer, and the tocodynamometer is applied to detect uterine contractions or fetal movement. Fetal activity may be recorded by the patient using an event marker or noted by the staff performing the test.
Option C: An internal monitor can be applied if the client is at 0-station. The Non-Stress Test (NST) is an assessment tool used from 32 weeks of gestation to term to evaluate fetal health through the use of electronic fetal monitors that continuously record the fetal heart rate (FHR). The test is used to determine if a fetus is at risk for intrauterine death or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal hypoxemia.
Option D: Contraction intensity has no bearing on the application of the fetal monitor. The NST involves 20 minutes of monitoring the FHR while assessing the number, amplitude, and duration of accelerations that usually correlate with fetal movement. A normal test result, as defined by the American College of Obstetrics and Gynecologist, is one in which two or more accelerations peak at 15 bpm or more above baseline, each lasting 15 seconds or more, and all occurring within 20 minutes of beginning the test.

Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. Provide clear fluids (e.g., clear broth, tea, cranberry juice, jell-O, popsicles) and ice chips, as permitted. Helps promote hydration and may provide some calories for energy production.

Option A: Impaired gas exchange related to hyperventilation would be indicated during the transition phase. Assess FHR changes during a contraction, noting decelerations and accelerations. Detects severity of hypoxia and possible cause. The fetus is vulnerable to potential injury during labor, owing to situations that reduce oxygen levels, such as cord prolapse, prolonged head compression, or uteroplacental insufficiency.
Option B: Instead of Impaired physical mobility, Risk for ineffective coping would be more appropriate at this stage of labor. Reinforce breathing and relaxation techniques during contractions. Minimizes anxiety and provides a distraction, which may block the perception of pain impulses within the cerebral cortex.
Option C: Fluid volume deficit is not correct in relation to the stem. Monitor intake & output. Note urine specific gravity. Encourage the client to empty the bladder at least once every 1 1/2–2 hr. Intake and output should be approximately equal, depending on degree of hydration. Concentration of urine increases as urine output decreases and may warn of dehydration. Fetal descent may be impaired if the bladder is distended.

This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Late decelerations are one of the precarious decelerations among the three types of fetal heart rate decelerations during labor. They are caused by decreased blood flow to the placenta and can signify an impending fetal acidemia.

Option A: Has no relation to the readings. The primary etiology of a late declaration is found to be uteroplacental insufficiency. Decreased blood flow to the placenta causes a reduced amount of blood and oxygen to the fetus.
Option B: Compressed umbilical cord results in a variable deceleration. The central pathophysiology behind late deceleration involves uterine contraction constricting blood vessels in the wall of the uterus which decreases blood flow through the intervillous space of the placenta, reducing diffusion of oxygen into fetal capillaries causing decreased fetal PO2.
Option C: A vagal response is indicative of an early deceleration. When fetal PO2 decreases, chemoreceptors initiate an autonomic response in the fetus causing intense vasoconstriction with increased blood pressure. The elevated blood pressure is perceived by the baroreceptors which ultimately stimulate the parasympathetic system to decrease the fetal heart rate, causing late deceleration.

The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Initial management of recurrent variable decelerations should have a target of relieving potential cord compression. Maternal repositioning is a reasonable first maneuver. Variable decelerations can be seen resulting from fetal movement if the fetus is premature.

Option A: Notifying the physician might be necessary but not before turning the client to her side. Recurrent variable decelerations during labor require evaluation. Initial evaluation includes characterization of the decelerations themselves, including their frequency, depth, and duration. It is also important to assess the uterine contraction pattern and the other fetal heart tracing characteristics.
Option B: Starting an IV is not necessary at this time. In specific clinical scenarios that may result in concerning variable decelerations, management should be directed by the etiology of those decelerations. If a patient is having uterine tachysystole, reducing the number of contractions by decreasing oxytocin or administration of a beta-agonist may be appropriate.
Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied incorrectly. Electronic fetal monitoring is utilized in approximately 85% of live births in the United States, making it the most common procedure in obstetrics. This frequency represents an increase since 1980 when its use was about only 45% of women in labor. Intermittent, variable decelerations, defined as decelerations occurring with less than half of contractions, are the most common fetal heart rate abnormality that takes place in labor.

Accelerations with movement are normal. Accelerations are transient increases in the FHR. They are usually associated with fetal movement, vaginal examinations, uterine contractions, umbilical vein compression, fetal scalp stimulation or even external acoustic stimulation. The presence of accelerations is considered a reassuring sign of fetal well-being.

Option A: The average fetal heart rate is between 110 and 160 beats per minute. The normal FHR range is between 120 and 160 beats per minute (bpm). The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. Prematurity, maternal anxiety and maternal fever may increase the baseline rate, while fetal maturity decreases the baseline rate.
Option B: Baseline variability is defined as fluctuations in the fetal heart rate of more than 2 cycles per minute. Marked variability is at >25 BPM. The FHR is under constant variation from the baseline. This variability reflects a healthy nervous system, chemoreceptors, baroreceptors and cardiac responsiveness. Prematurity decreases variability; therefore, there is little rate fluctuation before 28 weeks. Variability should be normal after 32 weeks.
Option C: If there are ominous periodic changes, it would indicate an abnormality in the fetal heart rate pattern. Fetal hypoxia, congenital heart anomalies and fetal tachycardia also cause decreased variability. Beat-to-beat or short-term variability is the oscillation of the FHR around the baseline in amplitude of 5 to 10 bpm. Long-term variability is a somewhat slower oscillation in heart rate and has a frequency of three to 10 cycles per minute and an amplitude of 10 to 25 bpm.