Maternity Nursing: Intrapartum Q 26
When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:
A. An acceleration
B. An early elevation
C. A sonographic motion
D. A tachycardia
Correct Answer: A. An acceleration
An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.
Option B: Increased variability in the baseline FHR is present when the oscillations exceed 25 bpm. This pattern is sometimes called a saltatory pattern and is usually caused by acute hypoxia or mechanical compression of the umbilical cord. This pattern is most often seen during the second stage of labor. The presence of a saltatory pattern, especially when paired with decelerations, should warn the physician to look for and try to correct possible causes of acute hypoxia and to be alert for signs that the hypoxia is progressing to acidosis. Although it is a nonreassuring pattern, the saltatory pattern is usually not an indication for immediate delivery.
Option C: Auscultation of the fetal heart rate (FHR) is performed by external or internal means. External monitoring is performed using a hand-held Doppler ultrasound probe to auscultate and count the FHR during a uterine contraction and for 30 seconds thereafter to identify fetal response. The transducer uses Doppler ultrasound to detect fetal heart motion and is connected to an FHR monitor. The monitor calculates and records the FHR on a continuous strip of paper.
Option D: Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm and is considered a nonreassuring pattern. Tachycardia is considered mild when the heart rate is 160 to 180 bpm and severe when greater than 180 bpm. Tachycardia greater than 200 bpm is usually due to fetal tachyarrhythmia or congenital anomalies rather than hypoxia alone.