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CASE STUDY A) SILVIA. Silvia, a 28-year-old G1P0000 at 39 1/7 weeks by sonogram, and her partner arrived on the labor unit at 0730 for scheduled induction for IUGR/FGR. Silvia's family history is negative for medical problems with the exception of her mother's long-term history of diabetes. Silvia has no history of medical problems and she has never had any surgeries. She developed gestational diabetes with this pregnancy, but her other prenatal labs were all normal. During one of the ultrasound examinations performed to evaluate the IUGR/FGR, a single umbilical artery was noted. On her most recent biophysical profile (BPP), the amniotic fluid index (AFI) was 11 cm (AFI less than 5 cm is defined as oligohydramnios) and the estimated fetal weight (EFW) was 2524 grams (7th percentile). WHAT FETAL HEART RATE DECELERATION IS MORE LIKELY TO OCCUR IN THE PRESENCE OF SILVIA'S SINGLE UMBILICAL ARTERY? - The Answer Is Variable decelerations The single umbilical artery impacts which component of the oxygen transfer system? - The Answer Is Oxygen delivery Which of Silvia's findings indicates a potential for chronic fetal hypoxemia? - The Answer Is Intrauterine growth restriction (IUGR)
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With the finding of a single umbilical artery, what would you expect to occur with fetal perfusion? - The Answer Is Decreased blood perfusion from the fetus to the placenta Silvia's admission vital signs were BP 109/60, pulse 83 bpm, respirations 18/minute, temperature 97F (36.6C). Vaginal examination findings were 2-3 cm dilated, 50% effaced, -1 station, membranes intact, and cephalic presentation. External electronic fetal monitor devices were placed (ultrasound and tocodynamometer). She denied having contractions, vaginal leaking or bleeding. Following this admission tracing, oxytocin was ordered and initiated at 2 mU/min. Within an hour, the rate was increased to 5 mU/min. PRIMARY BENEFITS ASSOCIATED WITH THE USE OF STANDARDIZED TERMINOLOGY FOR FHM INTERPRETATION IN THE CLINICAL SETTING INCLUDE:
The Answer Is Enhanced communication among health care providers and promotion of patient safety Refer to tracing A-1. Which is the correct assessment of the admission tracing? - The Answer Is Moderate variability Refer to tracing A-1. Based on this tracing, a necessary intervention would be to: - The Answer Is Readjust the toco
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Refer to tracing A-3. The correct assessment of this tracing includes: - The Answer Is Sinusoidal pattern Refer to tracing A-4. At the time of tracing 4, the resident performed an AROM and fluid was clear. A vaginal exam indicated the cervix was unchanged. The resident placed a fetal spiral electrode and had difficulty placing an IUPC. The nurse could palpate contractions but could not determine the frequency and duration by palpation. The oxytocin was discontinued, an intravenous fluid bolus was administered, and Silvia was repositioned. WHAT FHR CHARACTERISTICS SHOULD THE NURSE REPORT TO THE PROVIDER? - The Answer Is Recurrent decelerations Refer to tracing A-4. The correct physiologic interpretation of this tracing is: - The Answer Is Fetal hypoxemia may be present Refer to tracing A-5. At 1332, the resident successfully placed the IUPC and an amnioinfusion was initiated at
- The resident telephoned the provider to report the initiation of the amnioinfusion. WHICH INTRINSIC HOMEOSTATIC RESPONSE IS THE FETUS
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DEMONSTRATING? -
The Answer Is Baroreceptor Refer to tracing A-5. An amnioinfusion is intended to relieve which extrinsic factor that compromises oxygen transport? - The Answer Is Umbilical cord compression At 1410, the nurse again telephoned the provider to report Silvia's status, including two more dark red blood clots and absent variability with recurrent decelerations, and asked the provider to come to the bedside for evaluation. The provider indicated she was "on the way to the hospital" and ordered an emergency cesarean to be started by the senior resident. Silvia was prepped for cesarean birth. The nurse is planning to document her telephone report to the attending physician. Given the emergent situation, the best approach to documentation would be: - The Answer Is Continue providing care for Silvia and write a late entry summarizing the conversation after the cesarean is completed What additional action should the nurse take to minimize risk, based on this case scenario? - The Answer Is Ensure that the neonatal team is notified of the circumstances and is present for the birth
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Nell has had an exploratory lap. to remove scar tissue on her L ovary and intestines and has had infrequent menstrual cycles. She had has 2 SABs - at 12 and 5 weeks. Prenatal labs were WDL. Her thyroid is enlarged; however, her TSH, T4, and T3 were done at 39 weeks and were WDL. Nell has a family history of HTN. An US at 19 weeks revealed a low-lying placenta that resolved by 37 5/7 weeks. Today in triage, an US revealed an EFW of 3300g and an AFI of 3 cm. Nell has had reactive NSTs. Admission vital signs were WDL. SVE findings: fingertip, 40%, and -2 station. Membranes intact and cephalic presentation. Nell denied feeling regular cramping. Category I tracing. A vaginal prostaglandin insert was placed. WHICH COMPROMISE IN FETAL OXYGENATION COULD BE A RESULT OF A POST-DATE PREGNANCY? - The Answer Is Decreased placental perfusion What are the possible implications of an oligohydramnios for labor? - The Answer Is Potential umbilical cord compression If Nell's low-lying placenta had not resolved prior to labor and she experienced a large amount of bright red vaginal bleeding, possibly indicating hemorrhage, what FHM characteristic could occur? - The Answer Is Sinusoidal FHR pattern
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What clinical intervention is supported by Nell's gestational age and risk factors? - The Answer Is Continuous EFM monitoring throughout the night The prostaglandin was removed at 0600 and Nell took a shower and ate a light breakfast. An oxytocin infusion was then initiated at 2 mU/min. From 0730 to 0900 the FHR baseline was 150 bpm, moderate variability, occasional periodic variable decelerations and contractions every 2-5 minutes lasting 30-60 second, mild to moderate by palpation. Nell was coping well and reported her pain as a 2 on a scale of 1-10 during contractions. SVE 2/80/-2. Vital signs: 108/67, HR 119, RR 16, and T 98.2F (36.8C). Oxytocin was infusing at 10 mU/min. At 0925 Nell's provider performed AROM with return of thick, particulate yellow-green meconium. A fetal spiral electrode was placed. Refer to tracing B-1. Based on review of the tracing, the nurse's primary intervention is: - The Answer Is Auscultate the FHR with a doppler to confirm arrhythmia Refer to tracing B-1. In Nell's tracing, what do the FHR spikes likely represent? - The Answer Is FHR arrhythmia or artifact
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Refer to tracing B-2. Which assessment or intervention would be effective for increasing fetal oxygenation at this time? - The Answer Is Change maternal position to right lateral The fetal heart rate tracing continues for 45 minutes and is unresolved with intrauterine resuscitative measures. Nell's vaginal exam is unchanged. Nell is complaining of nausea and increased abdominal pain. Refer to tracing B-
- Based on a systematic assessment of the fetal heart rate tracing, the Category of this tracing is: - The Answer Is Category II Refer to tracing B-2. Based on the clinical scenario and the fetal heart rate tracing, the highest priority clinical course of action is to: - The Answer Is Alert the provider Refer to tracing B-2. Which of the following would be the most appropriate care as Nell is prepared for a cesarean delivery? - The Answer Is Transport Nell to the operating room and assess FHR before the abdominal prep Refer to tracing B-2. What pieces of information would be of highest priority to report to the neonatal team as they
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prepare for the delivery? - The Answer Is Gestational age, meconium, and FHR tracing A female was delivered by cesarean at 1211 and thick meconium was noted. Apgar scores were 4/5/7 at 1/5/10. Arterial umbilical cord gas results are: pH 7.26/pCO 56.5/pO2 23/BE -19. The newborn had a normal sinus rhythm, normal ECG, and echocardiogram and was discharged to home with mother. What is the most plausible explanation for the neonate's normal sinus rhythm at birth? - The Answer Is The source of the ectopic fetal cardiac stimulation had resolved CASE STUDY C) HELEN. Helen, a 23 year-old G3 P0020 at 25&6 comes to L&D with a chief complaint of "backache and cramping". Helen is a thin, young woman and her prenatal record indicates she was born prematurely. She's had 2 SABs and multiple uterine/vaginal infections, including treatment for dysplasia with a LEEP procedure. She began prenatal care at 16 weeks and attended 2 appointments due to transportation issues. Following a swab of the fluid in her vagina, which was negative for ferning, SVE findings were 2/70/-3, cephalic presentation. Helen denies recent sexual intercourse. States her baby is active today. FHR is auscultated at 156 bpm and external EFM components are placed. Demographic, obstetric, and socioeconomic factors provide essential information to
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Refer to tracing C-1. What typical characteristics of preterm uterine activity are present in Helen's tracing? - The Answer Is Low amplitude, high frequency contractions Which medications used with preterm labor can affect FHR characteristics? - The Answer Is Betamethasone and terbutaline What characterizes a preterm fetal response to interruptions in oxygenation? - The Answer Is More rapid deterioration from Category I to Category II or III Clinical decision-making at the bedside should include: - The Answer Is Integration of physiologic concepts with maternal-fetal assessment findings CASE STUDY D) MICHELLE. Michelle is a 31-year-old G1P at 38&6 who arrives to triage holding her abdomen while moaning in pain. Michelle reports a history of normal BP during this pregnancy and opioid use disorder. Abdominal pain started 12 hours ago and has increased in intensity. Michelle has had loose stools and kept down water and electrolyte drinks all day but continues to have the urge to have a bowel movement. Vital signs: T 97F (36.6C), BP
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165/105, HR 100, RR 23. The nurse uses a doppler for intermittent auscultation during the evaluation, auscultating a regular fetal heart rate rhythm within a normal baseline range. Michelle reports fetal movement. The nurse palpates Michelle's abdomen as intermittently strong contractions with periods of relaxed tone. Michelle reports more pain in right upper quadrant. WHICH MICHELLE'S PRESENTING HISTORY, WHAT IS THE NURSE'S FIRST PRIORITY CARE? - The Answer Is Reassess Michelle's blood pressure using the correct sized blood pressure cuff Michelles blood pressure continues to be elevated in the 165/105 to 180/110 range. Lab work is drawn and results are pending. Anticipated medical care for Michelle includes: - The Answer Is Antihypertensive therapy The perinatal team discussed Michelle's clinical picture with Michelle and her sister, including her elevated lab results. Her epigastric pain remains severe. The anticipated best plan of care includes admitting Michelle, continuing with antihypertensive therapy, and; - The Answer Is Starting magnesium sulfate
