Labor and
Delivery
Archer Review Crash Course
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Labor
Mom - The Four P’s
Powers
Passageway
Passenger
Psyche
Powers
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Pushing
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Voluntary
When fully dilated
Push during contractions
Contractions
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Involuntary
Uterine muscle contracts around fetus
Passageway
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Birth canal
Pelvis
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Does the baby have enough space to successfully pass through?
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Width
Passenger
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The baby
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Size
■ Macrosomia <4,000g
Tolerating labor?
■ HR decelerations
Psyche
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Emotions
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Fear
Anger
Joy
Excitement
Support
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Who is in the room?
Father
Doula
Doctor
Midwife
Baby
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Attitude
Lie
Presentation/Presenting part
Position
Station
Attitude
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The posture of the fetus
Relationship of fetal head to maternal spine
○ Flexion - normal
○ Neutral
○ Dorsiflexion
○ Extension
Lie
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Relationship of fetal and
maternal spines
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Longitudinal
■ Parallel spines
■ Normal
Transverse
■ Perpendicular
spines
Oblique
Presentation
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Presentation - The position of the baby in the birth canal
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Cephalic
■ Vertex
■ Brow
■ Face
Breech
■ Frank
■ Full
■ Footling
Cephalic Presentations
Breech Presentations
Vertex
Shoulder presentation
Presenting Part
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Presenting part - the part of the fetus that leads through the birth canal
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Head
Foot
Shoulder
Abdomen
Butt
Position
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The position of the baby in relation to the mom’s pelvis
Presenting part and the relationship of that part to the mom
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Anterior, posterior, or transverse
Right or left
Left occiput anterior
○
Most common
Station
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How far down in the
birth canal the baby is.
Measured in relation to
mom’s ischial spine
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Most narrow spot
At ischial spine = 0 station
Leopold Maneuvers
#1 - Fundal Grip
#2 - Umbilical grip
#3 - Pelvic Grip
#4 - Second Pelvic Grip
Labor and Delivery
Complications
Placenta Previa
Anatomy
Normal
Previa
Classifications of previa
The classification depends on where the placenta is located
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Complete
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The placenta is completely covering the cervix
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Partial
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Marginal
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Part of the placenta covers the cervix
Placenta covers only the edge of the cervix
Complete placenta previa
Partial placenta previa
Marginal placenta previa
Assessment
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Major symptom is PAINLESS bright red bleeding
The fact that it is painless is very important
That sets it apart from an abruption
To assess the bleeding
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Pad count to determine the amount
Clots
Color
Ultrasound done to confirm diagnosis
Ultrasound will determine type of previa
Nursing Interventions
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Never ever perform a vaginal exam if you suspect a placenta previa!
Would never want to irritate the placenta or uterus.
Continue to monitor for blood loss.
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Patient may have to stay on the unit to be monitored
Preform pad counts
Weigh pads
■ 1 gram = 1 mL blood loss.
Cesarean section indicated in most cases
Patient Education
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Bed rest
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Bleeding
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This may minimize blood loss
Report any bleeding that occurs
Monitor blood loss
Excessive amounts of blood loss may need treatment.
Monitor baby
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If there is excessive blood loss, perfusion to the fetus can be decreased.
NCLEX Question
You are triaging a new patient in the antepartum unit. They tell you that they started
bleeding this morning and were told to come in by their OB. They deny any pain or
other symptoms. Which of the following nursing interventions do you anticipate
initiating? Select all that apply.
a.
b.
c.
d.
Bed rest
Pad counts
Emergency vaginal delivery
Vaginal exam
Answer: A and B
A is correct. The nurse suspects a placenta previa based off of the clients complaint of painless bleeding. With a placenta previa, bed
rest is indicated to prevent further bleeding. This is an appropriate nursing intervention to initiate for both the safety of the mother
and fetus and should be done right away.
B is correct. Pad counts are a way of monitoring the quantity of blood loss. Because the nurse suspects placenta previa and the
patient is reporting vaginal bleeding, pad counts are an appropriate nursing intervention to initiate. When obtaining pad counts, they
can be done in two ways. If exact quantity of blood loss is not indicated, the nurse can just count the number of pads saturated with
blood. If the health care provider orders strict monitoring, the pads will be weighed to obtain the exact number of milliliters of blood
lost. When weighing pads, 1 gram is 1 milliliter of blood lost. Pad counts at a minimum should be initiated for any suspected placenta
previa, so this is an appropriate nursing intervention.
C is incorrect. An emergency vaginal delivery is contraindicated for a patient with suspected placenta previa. Because we believe that
the placenta is either partially or fully covering the cervix of this patient, a cesarean section will need to be performed. This may be
distressing for some mothers, so be sure to provide education about why this is the safest option for their and their baby’s health.
Vagnial deliveries with a placenta previa can cause serious harm to the mother and fetus, and are contraindicated.
D is incorrect. Vaginal exams are contraindicated for a patient with a suspected placenta previa. In this patient, we suspect that the
placenta is either partially or fully covering the cervix of this patient. That means that if a vaginal exam were to be performed, the hand
of the examiner would touch the placenta. We do not want to cause this irritation and exacerbate the bleeding that is already
occurring. Vaginal exams are always contraindicated on patients with either confirmed or suspected placenta previa.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
Subject: Maternal and Newborn Health
Lesson: Labor and Delivery
Abruptio
Placentae
Anatomy
Types
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Causes massive amounts of painful bleeding.
Two types
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Incomplete is only partial separation of the placenta.
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Incomplete
Complete
Causes internal bleeding
Blood backs up behind the placenta
Complete is when the placenta completely detaches
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Causes massive external bleeding
Very painful
Physiology
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Once the placenta has detached, it is no longer connected to maternal
circulation
This mena there is no more perfusion from mom to baby
No perfusion means no oxygen or nutrients.
This is why an abruption is considered a MEDICAL EMERGENCY ‘
The baby needs oxygen!
Stat c-section!!
Assessment
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Dark red bleeding
Intense abdominal pain
Board like abdomen (due to internal bleeding)
Rigid uterus
Hypotension (Think shock due to blood loss)
Maternal tachycardia
Fetal bradycardia (fetal distress!!)
Interventions
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Monitor for fetal distress
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Monitor maternal bleeding
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Signs of distress? Stat c-section!
Abdominal pain
Board like abdomen
Dark red vaginal bleeding
Change in fundal height (blood in abdomen?)
Keep the BP up with IVF and/or blood products
Prepare for delivery - most likely c-section.
Previa vs. abruptio
Previa - painless bleeding
Abruption - Painful bleeding
NCLEX Question
Which of the following signs and symptoms are expected for your patient
experiencing abruptio placenta? Select all that apply.
a.
b.
c.
d.
Painless bleeding
Dark red bleeding
Hypotension
Rigid abdomen
Answer: B, C, and D
A is incorrect. Painless bleeding is NOT a sign of abruptio placenta. Rather, it is a sign of placenta previa. In
placenta previa, the placenta is covering the cervix. This causes painless bleeding. In abruptio placenta, the
placenta separates from the wall of the womb. This causes a massive amount of very painful dark red bleeding.
It is important to remember the difference between these two emergencies. Placenta previa presents with
painless bleeding, and abruptio placenta presents with painful bleeding.
B is correct. Massive amounts of dark red bleeding is a prominent sign of abruptio placenta. This is due to the
placenta separating from the wall of the uterus. This massive amount of bleeding causes hypotension as the
mother enters hypovolemic shock, and fetal distress as perfusion to the baby decreases dramatically.
C is correct. Due to the massive amounts of dark red bleeding, hypotension is a sign of abruptio placenta.
When the mother loses large amounts of blood, her blood pressure will drop. This hypovolemia is treated with
IV fluids and/or blood products such as PRBCs.
D is correct. A rigid, board-like abdomen is a sign of abruptio placenta. This is also due to massive blood loss.
As the placenta separates from the wall of the womb blood starts to accumulate in the abdomen, causing it to
become rigid, and ‘board-like’.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
Subject: Maternal and Newborn Health
Lesson: Labor and Delivery
Dystocia
What is dystocia?
“Difficult birth, typically caused by a large or awkwardly positioned fetus, by smallness of
the maternal pelvis, or by failure of the uterus and cervix to contract and expand
normally.” (Perry et. al., 2013).
Causes
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Macrosomia
Malposition of the fetus
Hypotonic contractions
Hypertonic contractions
Maternal pelvis
Macrosomia
Extremely large fetus
Greater than 4,000 grams
Unable to fit through maternal pelvis
Malposition of fetus
Fetus is not in proper alignment for maternal pelvis.
Incorrect positioning means they will not be putting pressure on the pelvis
and therefore not causing dilation and effacement.
Maternal anatomy of pelvis plays a role too.
Hypotonic Contractions
Weak and ineffective contractions
Not able to work efficiently enough to get fetus through maternal pelvis
Hypertonic Contractions
Contractions are too strong and too fast.
So fast, that they are not allowing the uterus time to relax and refill with
proper nutrients.
Uncoordinated and not effective to cause dilation and effacement.
Maternal Pelvis
Anatomy of the maternal pelvis can play a role
If it is too narrow for the size of the fetus the shoulder can become stuck
during delivery (shoulder dystocia).
Assessment
Mother:
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Fetus:
Extreme pain (especially
with hypertonic
contractions)
Uncoordinated
contractions
Labor is not progressing
as expected.
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Dilation
Effacement
Station
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Fetal distress
If contractions are too
strong and too frequent
the placenta will not be
providing sufficient
oxygenation to the fetus.
Monitor fetal heart rate
for late decelerations.
Interventions
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Monitor for fetal distress
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Medications
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Notify the health care provider for any fetal distress
Pain medications
IV Fluids
Tocolytics
■ Given for hypertonic contractions
Oxytocin
■ Given for hypotonic contractions
Rest between contractions! Need to focus during contractions.
Patients with hypotonic contractions may be encouraged to walk to try
and get the contractions into a pattern.
Education
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Educate the mother about the pain she is experiencing and her options
for medication.
Positioning is important for optimal oxygenation to the fetus
○
Left side lying is encouraged.
NCLEX Question
Which of the following are causes of dystocia? Select all that apply.
a.
b.
c.
d.
Hypertonic contractions
Macrosomia
Hypotonic contractions
Breech presentation
Answer: A, B, C, and D
A is correct. Hypertonic contractions are contractions that are too strong and too frequent. This is a cause of dystocia. The
contractions are not effective in causing dilation and effacement, and do not help labor progress. They are extremely painful.
Treatment for mothers experiencing hypertonic contractions would include tocolytics and pain medication.
B is correct. Macrosomia is defined as a fetus that is much larger than average; greater than 4,000 grams. Because of the size of
these infants, it is difficult for them to fit through the maternal pelvis. This often causes a specific type of dystocia; shoulder
dystocia, where the shoulder of the infant essentially becomes stuck behind the pubic bone and causes prolonged and difficult
labor.
C is correct. Hypotonic contractions are contractions that are very weak and uncoordinated. They are a cause of dystocia. When
contractions are weak and uncoordinated they are ineffective in causing dilation and effacement and labor does not progress as
expected. Treatment would include oxytocin or helping the mother walk to get her contractions into a pattern.
D is correct. Breech presentation is one type of malpresentation that can cause dystocia. When the fetus is not lined up in a
cephalic presentation, fitting through the maternal pelvis becomes very difficult and causes dystocia.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
Subject: Maternal and Newborn Health
Lesson: Labor and Delivery
Break!
Back at...
Preterm Labor
Terminology
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Term - A baby born from 37-40 weeks gestation
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Preterm - A baby born between 20 and 37 weeks
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Preterm labor - Any labor occuring between 20 and 37 weeks
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Viability - The threshold at which an infant can survive outside the womb
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PROM - Premature Rupture of Membranes
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About 20 weeks gestation
Rupture of the membranes before labor begins.
PPROM - Preterm Premature Rupture of Membranes
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PROM that occurs before the 37th week of gestation, or prematurely.
Assessment
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Important to determine if it is true labor, or ‘false’ labor.
Many women experience Braxton Hicks contractions in their second and
third trimester, but these are not indicative of true labor.
Assessment of true labor
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Contractions at regular intervals.
Contractions of increasing intensity
Pelvic pain
Lower back pain
Rupture of membranes
Interventions
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Try to stop labor!
If at all possible, we want contractions to stop so that the pregnancy can
continue and the baby can be born at a normal gestational age.
Ways to stop labor:
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Tocolytics
■ Terbutaline
■ Magnesium Sulfate
Bedrest
Fluids
Must monitor both mother and baby closely
Evaluate the mothers contractions and their frequency, and how the fetus
is tolerating the contractions.
If PROM or PPROM monitor closely for infection.
Obstetric Medications
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Tocolytics - slow contractions
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Terbutaline
Magnesium-sulfate
Indomethacin (prostaglandin inhibitor)
Nifedipine (CCB)
Oxytocics - stimulate contractions
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Oxytocin
Ergometrine (Methergine)
Misoprostol
Education
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Most important educational point for mothers is what the signs and
symptoms of true labor are, so that they know when to call their doctor.
Teach mothers to call their OB for:
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Rupture of membranes
Regular contractions
Contractions that become stronger and more frequent with walking (Braxton Hicks will
fade away with walking)
Back pain
Once preterm labor has begun, educate mothers about tocolytics and the
importance of bedrest.
NCLEX Question
Which of the following are symptoms of true labor? Select all that apply.
a.
b.
c.
d.
Contractions that dissipate with walking
Contractions that come in regular intervals
Lower back pain
Contractions of consistent intensity
Answer: B and C
A is incorrect. Contractions that fade away with activity, a change in position, or rehydration are not a sign of true labor. These
are more likely Braxton Hicks contractions, which do not indicate labor. They are ‘practice contractions’ for the uterine muscle.
True contractions will not fade with activity, come in regular intervals, become closer together as time goes on, and become
more intense as time goes on.
B is correct. Contractions that come in regular intervals are a sign of true labor. You should educate mothers to seek care for
contractions that come in regular intervals, and become stronger and closer together with time. These contractions also will not
go away with a change in position or activity.
C is correct. Lower back pain is in fact a sign of true labor. Both lower back pain and pelvic pain indicate true labor, and mothers
should be educated to seek treatment when such treatments present. ‘False’ labor, or braxton hicks, do not present with these
symptoms. They are much weaker than contractions, and typically subside with a change in position or by going on a short walk.
D is incorrect. Contractions of consistent intensity indicate braxton hicks, or ‘false’ labor. When a mother is in true labor, her
contractions will increase in intensity over time. Education should be provided on the difference between braxton hicks and true
labor so that mothers know when to call their OB and seek treatment.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
Subject: Maternal and Newborn Health
Lesson: Labor and Delivery
PROM
Definition
The rupture of membranes before labor
begins.
“Rupture of membranes” is when the amniotic
sac breaks - when someone says their water
broke this is what they mean.
This is supposed to happen after labor starts.
With the amniotic sac intact there is a buffer
between the uterus and the infants preventing
contractions. The lack of this can stimulate
contractions.
Assessment
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Whenever the membranes rupture, always assess the color amount and
odor.
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Should be clear
Should not have a foul odor
Can be just a small amount of fluid up to a few hundred mLs.
If the membranes are yellow, green, malodorous, etc…. Worry about infection!!
Infection is the major concern with PROM, so that is what your
assessment with focus on.
Temperature
WBCs
CRP
Interventions
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Nitrazine test
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Monitor for infection
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pH test that differentiates amniotic fluid from urine or other secretions.
Strip will turn blue if the fluid is amniotic fluid
This will confirm rupture of membranes
Temperature
WBCs
CRP
Antibiotics if indicated
Fetal monitoring
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○
Heart rate
Decelerations
NCLEX Question
Which of the following statements is true regarding premature rupture of membranes (PROM)?
Select all that apply.
a.
b.
c.
d.
PROM is when the membranes rupture before 37 weeks gestation.
Membranes are expected to rupture before labor begins
A priority nursing intervention with PROM is to monitor for infection.
When observing the fluid after rupture of membrane, it should be clear and without odor.
Answer: C and D
A is incorrect. PROM stands for Premature Rupture of Membranes. This is defined as the rupture of membranes (or “water
breaking”), before labor begins. This term is not related to at what gestation the membranes rupture. If the membranes rupture
before 37 weeks gestation, the correct terminology is PPROM. This stands for Preterm Premature Rupture of Membranes. The
Preterm part of this acronym is what refers to the membranes rupturing before 37 weeks gestation.
B is incorrect. It is not expected that the membranes will rupture before labor begins. In a normal delivery, there is rupture of
membranes after the mother has begun having regular contractions, dilating, and effacing. When the membranes do rupture
before labor has started, it is called PROM, or premature rupture of membranes.
C is correct. A priority nursing intervention with PROM is to monitor for infection. When the membranes are ruptured before
labor begins, the baby is then exposed to bacteria and pathogens of the outside world. These germs can enter the birth canal
and infect both the mother and the infant. One of the most important observations you must make is of the color, odor,
consistency, and amount of the amniotic fluid when the rupture of membranes occurs. Any discolored or malodorous fluid may
indicate an infection. After the rupture of membranes occurs, the nurse should monitor the mother's temperature, WBC count,
CRP, and other markers of infection.
D is correct. It is very important to assess the color, odor, consistency, and amount of fluid when rupture of membranes occurs.
If the fluid is green or yellow and malodorous, it is indicative of infection. If the fluid is brown or black it is indicative of
meconium passing in utero. The expected finding of amniotic fluid is a clear fluid with no odor.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
Subject: Maternal and Newborn Health
Lesson: Labor and Delivery
Postpartum
Hemorrhage
What is it? Why is it important
Postpartum hemorrhage is the major loss of blood (hemorrhage) after a
vaginal delivery.
Can occur immediately after the delivery, up until 2 weeks after delivery
(delayed postpartum hemorrhage)
It is one of the major causes of maternal mortality! Almost 3% of women in
the US will experience PPH to some degree!!
More info: http://www.pphproject.org/maternal-morbidity-mortality.asp
Risk factors for PPH
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Twins or triplets
Macrosomic fetus
Preeclampsia
Prolonged labor
Precipitous labor
Use of forceps or vacuum during delivery
Placenta previa
Abruptio placenta
Causes
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Uterine atony
○
○
○
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This is the inability of the uterus to contract
Typically after birth, the uterus contracts to clamp down on all of the blood vessels and
stop the bleeding
If the uterus does not contract, or ‘clamp down’ hemorrhage will occur.
This is the most common cause of PPH
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Injury to the birth canal
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Retention of the placenta
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○
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Could be due to malpresentation of the fetus, use of forceps or vacuum, or a large fetus
If the entire placenta is not expelled within 30 minutes of delivery, the mother is at risk for
PPH
Bleeding disorders
○
○
DIC
Mothers on lovenox or warfarin for pre-existing conditions.
Definitions
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2 types of PPH
○
○
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Early - Occurs in the first 24 hours post delivery
Late - Occurs after the first 24 hours post delivery
To qualify as PPH, the mother must lose 500 ml of blood if she had a SVD
and 1,000 ml of blood if she had a cesarean section.
Assessment
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Boggy uterus
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○
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Blood loss
○
○
○
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This is a uterus that is not contracting to clamp down on the blood vessels
The fundus will feel soft instead of hard as it should.
Pad counts - most PPH patients are saturating pads every 15 minutes
Puddle of blood in the bed
If they try to stand up for the first time there could be a huge gush of blood
Shock - if there is large amounts of blood loss leading to hypovolemia
○
○
○
○
○
Decreased LOC
Pale
Diaphoretic
Hypotensive
Tachycardic
Interventions
●
Fundal massage
○
○
○
●
Estimated Blood Loss (EBL)
○
○
○
●
Massage the fundus - hard!
Warn the mother this will hurt, but you must do it to get the uterus to contract and stop
the bleeding.
Every 15 minutes at a minimum
Weigh pads to estimate the loss
1 g = 1 mL
Monitor hemoglobin and hematocrit
Mediations
○
○
○
Oxytocin
Methylergonovine
Blood products
NCLEX Question
Which of the following conditions are considered a risk factor for women to experience
postpartum hemorrhage? Select all that apply.
a.
b.
c.
d.
Microcephaly
Dystocia
Placenta previa
Singleton pregnancy
Answer: B and C
A is incorrect. Microcephaly is a newborn complication where the newborn is born with a head smaller than average.
This is not a risk factor for a woman to experience postpartum hemorrhage. If you selected this answer, you may
have gotten it confused with macrosomia, a condition where the infant is larger than average, specifically greater than
4,000g. This is a risk factor for postpartum hemorrhage.
B is correct. Dystocia, a prolonged and difficult labor, is a risk factor for postpartum hemorrhage. Prolonged labor
specifically can dramatically increase the risk for postpartum hemorrhage.
C is correct. Placenta previa is a risk factor for postpartum hemorrhage. In placenta previa, the placenta is covering
the cervix of the mother rather than sitting in the fundus of the uterus as it should be. This puts the mother at risk for
postpartum hemorrhage.
D is incorrect. A singleton pregnancy, or a pregnancy with only one fetus does not pose a risk for postpartum
hemorrhage. The risk factor for postpartum hemorrhage is with multiples; such as twins or triplets.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.
Subject: Maternal and Newborn Health
Lesson: Labor and Delivery
Prolapsed Umbilical Cord
What is a prolapsed cord?
●
●
●
Umbilical cord slips
through the cervix and into
the vagina after rupture of
membranes and before the
baby descends into the
birth canal.
During delivery, the
prolapsed cord become
compressed by the
presenting part of the fetus
This cuts off oxygen to the
fetus
Assessment
●
●
Cord visualized protruding through vagina
Cervical exam
○
○
○
Something squishy?
Pulsing?
Mom feels something between legs
Nursing Interventions
●
●
●
Elevate the presenting part of the fetus off of the prolapsed cord
Keep your hand on the baby’s head lifting it up and call for help
Positioning
○
○
●
●
●
●
Knees-to-chest position - open the pelvis
Trendelenburg - let gravity shift the baby off the cord
Administer oxygen
NEVER ATTEMPT TO PUSH THE CORD BACK IN!!!!
Wrap cord in sterile moist towel
Emergency Cesarean delivery
Fetal Heart
Monitoring
Terminology
Variability
●
Fluctuation in the fetal heart rate
Acceleration
●
A speeding up of the fetal heart
rate
Deceleration
●
A slowing down of the fetal heart
rate
Reassuring
●
The baby looks healthy!
Non-reassuring
●
Something is wrong with the baby
Variability:
● Absent
● Marked
● Moderate
Absent Variability - Bad!
Marked variability - Can be either bad or good!
Moderate variability - Good!
Accelerations
Accelerations
Decelerations
● Early
● Variable
● Late
Early decelerations
Variable decelerations
Late decelerations
VEAL CHOP
V - Variable
E - Early
A - Acceleration
L - Late
C - Cord Compression
H - Head Compression
O - Okay
P - Placental Insufficiency
Reassuring
●
●
●
Baseline heart rate in the
normal range: 110-160
Moderate variability
Accelerations
Non-Reassuring
●
●
●
●
●
Fetal tachycardia - HR >160
Fetal bradycardia - HR <110
Decreased variability
Variable decelerations
Late decelerations
Nursing Interventions - Non-reassuring fetal heart rate
LION PIT
L: Lay the mother on her LEFT side
I: Increase IV fluids
O: Oxygen
N: Notify the healthcare provider
PIT: Discontinue Pitocin
NCLEX Question
The nurse is taking vital signs on a pregnant client in active labor. When she
inflates the blood pressure cuff, she looks at the fetal monitor and notices that the
fetal heart rate increases above baseline, and then returns to baseline about 15
seconds later. What is the priority nursing action?
a.
b.
c.
d.
Notify the healthcare provider.
Document and continue to monitor
Place the mother on her left side
Administer 100% FiO2 via face mask
Answer: B
A is incorrect. The nurse has observed an acceleration in the fetal heart rate. This is when the fetal heart rate increases by 15
bpm above the baseline. An acceleration lasts about 10-15 seconds, and then the heart rate returns to baseline, as the nurse
observes in this question. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip, and do not need to
be reported to the healthcare provider.
B is correct. Because the nurse has noted a reassuring sign of the fetal heart rate, it is most appropriate for her to document
the finding and continue to monitor the mother. IF the nurse had noticed a non-reassuring sign, other interventions would be
necessary.
C is incorrect. The nurse has observed an acceleration in the fetal heart rate. This is when the fetal heart rate increases by 15
bpm above the baseline. An acceleration lasts about 10-15 seconds, and then the heart rate returns to baseline, as the nurse
observes in this question. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip, and do not require
repositioning of the mother to the left side.
D is incorrect. The nurse has observed an acceleration in the fetal heart rate. This is when the fetal heart rate increases by 15
bpm above the baseline. An acceleration lasts about 10-15 seconds, and then the heart rate returns to baseline, as the nurse
observes in this question. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip, and do not require
administration of 100% FiO2 via face mask.
NCSBN Client Need:
Topic: Effective, safe care environment Subtopic: Coordinated care
Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.
Subject: Maternity Nursing
Lesson: Problems with Labor and Delivery
NCLEX Question
The nurse assists a mother in labor to the bathroom, and notes that the fetal heart
rate increases from 130 to 190. She sits the mother back down in bed, and the fetal
heart rate remains 190. Which of the following nursing actions would be
appropriate? Select all that apply.
a.
b.
c.
d.
Lie the mother down on her left side
Decrease the rate of her IV fluids
Administer oxygen
Continue to monitor the mother
Answer: A and C
A is correct. The nurse has noted fetal tachycardia. Any increase in fetal heart rate above 160 is considered
tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention. Any
nonreassuring fetal heart rate will require intervention. You can remember these interventions with the mnemonic
LION: lie the mother on her left side, increase IV fluids, oxygen, and notify the healthcare provider. In this case, the
nonreassuring sign of fetal tachycardia necessitates intervention, and lying the mother on her left side is an
appropriate intervention
B is incorrect. Decreasing the rate of the mother’s IV fluids is not appropriate. Instead the nurse should increase the
rate of IV fluids to help better facilitate blood perfusion to the placenta and fetus. Increasing not decreasing the fluids
is the appropriate nursing intervention.
C is correct. Administering oxygen is an appropriate nursing intervention for the noted fetal tachycardia. This will go
along with repositioning the mother on to her left side, increasing the rate of IV fluid administration, and notifying the
healthcare provider.
D is incorrect. It is inappropriate to simply continue to monitor the mother. The nurse has noted fetal tachycardia, a
nonreassuring sign that requires intervention. The nurse should lie the mother on her left side, increase her IV fluids,
administer oxygen, and notify the healthcare provider.
NCSBN Client Need:
Topic: Effective, safe care environment Subtopic: Coordinated care
Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.
Subject: Maternity Nursing
Lesson: Problems with Labor and Delivery
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