The nurse providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by: a. Altered fetal cerebral blood flow. Interventions for late decelerations are: Lower the head of the bed and turn the mom on her left side to take the pressure off the vena cava and allow blood flow to the heart and to the lungs. Welcome to Maternal and Child Health Nursing (HESI EXAMINATION) Prepared by: Jeffrey Viernes There are basically 3 positions that your baby can be in; breach, shoulder and arm, and cephalic (head first). An abnormal bleeding episode may lead to complications in pregnancy such as uteroplacental hypovolemia or hypoxia. Some nursing interventions include: turn mom onto her side, stop Picotin if infusing, administer 10 L of O2, maintain IV access, determine the Fetal Heart Rate variability, and contact doctor. Nursing Care Plan 2. allnurses is a Nursing Career & Support site. Fetal heart rates less than 100 indicate fetal bradycardia; and rates greater than 160 beats per minute indicate fetal tachycardia. a. Fetal tachycardia is an abnormal increase in the fetal heart rate.It is variably defined as a heart rate above 160-180 beats per minute (bpm) and typically ranges between 170-220 bpm (higher rates can occur with tachyarrhythmias). b. Greeting the client on arrival, assessing her, and starting an intravenous line. Nursing Care Plans. Nursing Diagnosis: Fluid volume deficit related to failure of regulatory mechanism secondary to meconium aspiration syndrome. Chorioamnionitis: Prevention and Nursing Management After 20 hours of labor Ms. B, G1P0, now has a temperature of 38 degrees C, her abdomen is tender to the touch and the internal fetal scalp electrode is showing fetal tachycardia with a baseline fetal heart rate of 170. • Describe nursing measures that can be used to maintain fetal heart rate patterns within normal limits. T or F. True -amnioitis is infection of the uterus or amniotic sac. Mild fetal tachycardia is described as 161-180bpm and severe tachycardia is defined as greater than 180bpm for at least three minutes. Provide explanation to woman and partner. Baseline FHR Variability. The nursing care plan for patients with perinatal infection involves screening/identifying for prenatal infection, providing information about the protocol of care and promoting client/fetal well-being. ... nursing interventions, and response to interventions. In PIH and chorioamnionitis, steroid therapy may aggravate hypertension and mask signs of infection. Since 1997, allnurses is trusted by nurses around the globe. Lowdermilk: Maternity Nursing, 8th Edition Chapter 11: Fetal Assessment during Labor Test Bank MULTIPLE CHOICE 1. Auscultate and report FHR; note bradycardia or tachycardia. Supraventricular tachycardia (SVT) is an abnormally fast heartbeat that originates above the ventricles in the atria or AV node. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. Learn how to carry out a systemic fetal assessment, including establishing a baseline. A baseline tachycardia; Early decelerations; These fetal heart rate patterns do not indicate fetal distress but warn that the woman should be closely observed as there is an increased risk that fetal distress may develop. Since 1997, allnurses is trusted by nurses around the globe. Record the maternal blood pressure, pulse, and respirations every 30 to 60 minutes and with each dosage increase. Assess signs and symptoms of infection (e.g., elevated temperature, pulse, WBC; abnormal odor or color of vaginal discharge, or fetal tachycardia). Nursing Interventions Rationale; Assess maternal physiological circulatory status and blood volume. and (3) to examine the amount of nursing time re- quired to perform NSTs induced by spontaneous fetal movement as compared to stimulated fetal movement. The subjects (n = 125) were selected from among patients who were referred for NSTs by the private and clinic obstetric services division of the Albany Medical Center Hospital. Fetal distress presents in varied ways and to differing degrees. Nursing interventions for early decels. If it is sinus tachycardia, treat the cause. Assisting the Client with Performing/Learning Newborn Care Mothers, particularly new mothers and significant others, need some assistance and support in terms of newborn care and infant feeding. Requires nursing intervention to improve blood flow and fetal oxygen supply; VEAL CHOP. Fetal Assessment Worksheet. ~ ~ ~~~~ Figure 1 Nursing protocol for intrauterine treatment o fetal tachycardia. Ectopic pregnancy is a medical condition wherein the zygote fails to attach to the uterus and will either be on the fallopian tubes, the cervix, or any other part of the female reproductive system. Pattern Nursing Interventions Variable decelerations Isolated or occasional Moderate Variable decelerations Severe and uncorrectable Late decelerations Late decelerations with tachycardia or decreasing variability Prolonged decelerations Report findings to physician/CNM and document in chart. MENNONITE COLLEGE OF NURSING . Our members represent more than 60 professional nursing specialties. Nursing Outcomes:-Pt will be free from any signs and symptoms of infection such as foul smelling/looking vaginal drainage, elevated temperature, uterus tenderness or rigidness, diminished fetal movement, tachycardia, and hypo-tension throughout rest of pregnancy.-The patient will verbalized 6 signs and symptoms of infection to the nurse. Note: This is a key nursing intervention so you have to keep this in mind. 1. Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. allnurses is a Nursing Career & Support site. Steroids may increase … f and the fetus. Note change in hypoactivity or hyperactivity. Illinois State University. Ectopic Pregnancy NCLEX Review Care Plans. Cardiotopography consists of monitoring the fetal heart rate, in the absence of uterine activity or the presence of contractions. View causes of fetal tachycardia, bradycardia, and hypoxia. By the way, kudos to the OB RNs out there! Baseline variability is defined as fluctuations in the fetal heart rate of more than 2 cycles per minute.No distinction is made between short-term variability (or beat-to-beat variability or R-R wave period differences in the electrocardiogram) and long-term variability.. Grades of fluctuation are based on amplitude range (peak to trough): She has been on bedrest after Nursing Interventions Rationale; Assess for maternal conditions that would contraindicate steroid therapy to facilitate fetal lung maturity. In nursing, the acronym VEAL CHOP can be used to remember the types of fetal heart rate patterns and the causative factors associated with them. . Differentiate among the nursing interventions used for managing specific fetal heart rate patterns, including tachycardia and bradycardia, absent or minimal variability, and late and variable decelerations. NCLEX and HESI may ask what is causing this type of strip and the answer would be uteroplacental insufficiency. • Differentiate among the nursing interventions used for managing specific fetal heart rate patterns, including tachycardia and bradycardia, absent or minimal variability, and late and variable decelerations. Variability (01:28) Irregular fluctuations in fetal baseline are a primary indicator of adequate fetal oxygenation. If electronic monitoring is available, all these high risk fetuses should be monitored continuously by CTG. c. Applying the external fetal monitor and notifying … If the fetus does not respond to primary nursing interventions for late decelerations, the nurse should continue with subsequent intrauterine resuscitation measures, including notifying the health care provider. Here are three (3) nursing care plans (NCP) and nursing diagnosis for … Nursing Study Guide on Ectopic Pregnancy. Intrapartum fetal monitoring was developed in the 1960s to identify events that might result in hypoxic ischemic encephalopathy, cerebral palsy, or fetal death. It may be suspected by the following, which may also be used for further evaluation of suspected fetal distress: Clinical suspicion when decreased fetal movements are felt by the mother or there is a slowing or stopping of the growth of serial symphysis fundal height. Usually benign 2. consider stage of labor 3. may be sign advanced dilation or beginning of 2nd stage. Rupture of membranes occurring 24 hr before the surgery may result in chorioamnionitis prior to surgical intervention and may impair wound healing. Uterine contractions and umbilical cord compression decrease blood flow. b. Umbilical cord compression. Our members represent more than 60 professional nursing specialties. Breach means the baby is coming feet or butt first which only happens in about 3% of births. at . Anxiety, fever, pain, shock states, can all be some of the causes of sinus tachycardia. c. Uteroplacental insufficiency. Record intake and output. Fetal tachycardia (sustained rate above 160 beats per minute [bpm]) often precedes maternal fever. Intrapartum emergencies are challenging to all perinatal nurses because of the increased risk of adverse outcomes for the mother and fetus. Treating the tachycardia with chemicals without fixing the cause will only lead to further problems. Occurs in 5% of pregnancies. 'Outcome depends on medical as well as nursing interventions. Amnionitis may be the first sign of fetal tachycardia. It also gives you a clue as to what the correlating nursing interventions should be for each pattern. Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes. Maternal Infant Nursing -316. The purpose of this worksheet is to guide your understanding of the normal fetal heart rate patterns, variations in heart rate patterns during labor, components of the biophysical profile, tests of fetal maturity, and antenatal testing interpretation. Perinatal emergencies, such as seizures, amniotic fluid embolus, hemorrhage, and uterine rupture, create physiological challenges and trigger intrinsic survival techniques. For many people, treatment and lifestyle changes can control or eliminate this heart rhythm problem. The most rare presentation is the shoulder and arm position which means that the baby is …