Which intervention would the nurse initiate when a fetal heart pattern signifying Uteroplacental insufficiency?

Nitrazine Test FOR pH

Read Results

Yellow	pH 5.0
Olive-yellow	pH 5.5
Olive-green	pH 6.0

 Membranes probably ruptured: identifies amniotic fluid that is alkaline

Blue-green	pH 6.5
Blue-gray	pH 7.0
Deep blue	pH 7.5

Document Results

 Results are positive or negative.

Test for Ferning or Fern Pattern

Document Results

 Results are positive or negative.

Latent Phase (dilation of cervix 0-3 cm; contractions 30-45 sec long, 5-30 min apart, mild to moderate intensity; duration of phase about 6-8 hr)

Active Phase (dilation of cervix 4-7 cm; contractions 40-70 sec long, 3-5 min apart, moderate to strong intensity; duration of phase about 3-6 hr)

Transition Phase (dilation of cervix 8-10 cm; contractions 45-90 sec long, 2-3 min apart, strong intensity; duration of phase about 20-40 min)

BOX 3-4

Procedure for Intermittent Auscultation of the Fetal Heart Rate

1. Palpate the maternal abdomen to identify fetal presentation and position.

2. Apply ultrasonic gel to the device if using a Doppler ultrasound. Place the listening device over the area of maximal intensity and clarity of the fetal heart sounds to obtain the clearest and loudest sound, which is easiest to count. This location will usually be over the fetal back. If using the fetoscope, firm pressure may be needed.

3. Count the maternal radial pulse while listening to the fetal heart rate (FHR) to differentiate it from the fetal rate.

4. Palpate the abdomen for the presence or absence of uterine activity (UA) so as to count the FHR between contractions.

5. Count the FHR for 30 to 60 sec between contractions to identify the auscultated rate, best assessed in the absence of UA.

6. Auscultate the FHR before, during, and after a contraction to identify the FHR during the contraction, as a response to the contraction, and to assess for the absence or presence of increases or decreases in FHR.

7. When distinct discrepancies in the FHR are noted during listening periods, auscultate for a longer period during, after, and between contractions to identify significant changes that may indicate the need for another mode of FHR monitoring.

Source: Tucker, S., Miller, L., & Miller, D. (2009). Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach (6th ed.). St. Louis: Mosby.

NURSING ALERT

When the FHR is auscultated and documented, it is inappropriate to use the descriptive terms associated with electronic fetal monitoring (e.g., moderate variability, variable deceleration) because most of the terms are visual descriptions of the patterns produced on the monitor tracing. Terms that are numerically defined, however, such as bradycardia and tachycardia, can be used. Fetal heart rate when auscultated should be described as a baseline number or range, and as having a regular or irregular rhythm. The presence or absence of accelerations or decelerations both during and after contractions should also be noted.

There are two modes of electronic FHR and contraction monitoring: external and internal. See Table 3-1 for differences in these monitoring modes.

TABLE 3-1

External and Internal Modes of Monitoring

ECG, Electrocardiogram; FHR, fetal heart rate.

Figure 3-5 shows an example of accelerations. Box 3-5 lists causes, clinical significance, and nursing interventions for accelerations.

Figure 3-6 shows an example of early decelerations. Box 3-6 lists causes, clinical significance, and nursing interventions for early decelerations.

Figure 3-7 shows an example of late decelerations. Box 3-7 lists causes, clinical significance, and nursing interventions for late decelerations.