Now for fetal heart rate monitoring. Hey guys, I'm nurse Mike here with nurse Barbara and today we're going to be going over all the key points that you need to know for your exams as well as the enclelex. Now before we get into it, my simple nursing members out there, be sure to find this study guide in your membership to make sure this knowledge really sticks. All right, let's go. Now, fetal heart rate monitoring is a way to identify fetal well-being and oxygenation during labor. During labor, it is vital to monitor both the uterine contractions and the baby's heart rate as an abnormal reading may indicate that the baby is not getting enough oxygen or other problems are occurring. Now, there are two types of devices used for external fetal monitoring. The sono or ultrasound is used for the baby's heart rate and the toco or tocoter is used for the mom's uterine activity. The mother's abdomen is palpated for fetal position to find that point of maximal impulse, the PMI, which is located between the baby's shoulder blades, and this is where the baby's heart rate can be heard the loudest. Now, this is the best place to put the fetal heart rate sensor. Now, for Mike for some dramatization purposes, the point of maximum impulse. Thanks for that, Mike. Now the PMI is found between the baby's shoulders. Now if the baby is syphalic or head down, it will be placed on the mother's lower abdomen. But if the baby is breached, the monitor will find the PMI in the upper abdomen. Now board exams love to test on this and they often ask students to click on the area of the abdomen where the PMI would be found based on the fetal position. So be sure to write that down. And finally, we have a second sensor which is the contraction monitor sensor. And this is placed high up on the mother's abdomen to monitor the contractions. Now, a more accurate but invasive method of monitoring the baby is an internal fetal monitor, also called a fetal scalp electrode, the FSE. And this is typically only used for high-risisk pregnancies. This method uses a thin wire electrode and is placed directly on the baby's scalp through the cervix. This method gives better readings as it's not affected by movement. It can only be used after the amniotic sack has ruptured and the cervix is open to at least 2 cm in dilation. Now, the FSE does come with a high risk of infection since we are placing a foreign object into the mother's vagina and onto the baby's head. Now for an ATI question. Which of the following must be present before the nurse initiates internal fetal monitoring and this would be a cervical dilation of at least 2 cm. Okay. So now let's review how a normal fetal heart rate monitor tracing looks. And then we will go through the top seven strips to know for the ENLEX and your nursing school exams. As you can see, there are two strips here showing squiggly lines similar to an EKG. The fetal heart rate is on top, which we always assess first, and the mother's contractions are on the bottom. Those double red lines represent one minute in time. So, now on to nurse Mike for a discussion of fetal heart rate. Thanks, nurse Barbara. What of maximum? I'm just kidding. Okay, so for some key terms for the fetal heart rate baseline. So normal fetal heart rate is 110 to 160 beats per minute. Variability is basically how jiggly or wiggly the line is. So as labor progresses, we expect the fetal heart rate to have wiggly lines. This is called variability. So it means a happy baby and it means the neurosystem is intact. So in general we say the more wiggly the more happy the baby. Now, we have different types of variability, kind of like a traffic light. The red light is where we stop what we're doing and run to get the baby out. This red light is absent variability. We have no jiggly, which is not good. The baby's not responding and is at risk for major complications and even death. The baby needs to come out right now via C-section. Now, the next big one is minimal variability. This is our yellow light. It is seen as a flatter line and kind of looks sleepy and sad. Typically meaning that the baby is either sleeping or in trouble and it's very concerning since we see less jiggly so basically less happy of a baby. The next one is moderate variability. Now this is our green light. It's normal and the desired finding. So the memory trick for moderate just think it's the most desired. And the last one here is marked variability. we see jagged jiggles. So this is our stressed out baby. But this baby is okay as it typically is seen during labor as the baby is being pushed out. Now the most commonly tested are the minimal and moderate variability. So please be sure to focus on these top two squiggles. Okay. The next key term to know is accelerations. These are temporary increases in the fetal heart rate and it indicates great oxygenation for the baby. We call these happy little mountains. So cute. These are little bonus points that shows the baby is doing well. So the memory trick, the baby gets A's for accelerations. Now the next is decelerations. We see big dips from the baseline. And there are three different types. We always look at the shape and timing with each contraction. So first up is early D cells. Now these are good. They look like shallow bull-shaped dips that mirror the mother's contraction. As you can see on our little chart, the top line and bottom line are attracted to each other, kind of like a magnet. Then it goes back to baseline between contractions. It indicates head compression, which is totally expected during labor. And the memory trick here, it's good to be early with early D cells. Or you can think you want to show up early to the party with that dip for the chip. So don't be late with that chip dip. The party's going to be angry. The next del is variable D cells. So just look for the V's here. It is very concerning with very deep sharp V dips. See how deep the fetal heart rate dips on top. Now this indicates cord compression which cuts off oxygen to the fetus. So, we'd want to change the mom's position and even consider an amnneo infusion if that position change doesn't fix the problem because remember very deep dips are very concerning indicating variable D cells. Now, lastly, late D cells are bad. They are the worst. It indicates decreased oxygenation basically hypoxia. But the differences here are very subtle. So, look at our chart here. See how the fetal heart rate is dipping on top and how it comes after that big uterine contraction bump right on the bottom. So remember, don't be late with that chip dip. That party is going to be very angry. It's a very bad sign. Don't be late with that dip. So once again, the memory trick here is it's bad to be late to the party. Don't be late with the chip dip. Now, key terms for uterine contractions. During contractions, babies will hold their breath and fetal oxygenation is impaired. So knowing this is vital to keep the baby well oxygenated. Now there are four components to know. First is frequency. So this is the frequency of contractions and measuring how far apart the contractions are. Starting at the beginning of one contraction all the way to the beginning of the next contraction. And remember that it's measured in minutes. Next is the duration of contractions and this measures how long the contractions last. Simply count the small boxes under the hill of the contraction and remember these are measured in seconds. Number three is the intensity of contractions and this is a rating of how strong the contractions are. For an external monitor, the nurse must palpate the uterine tone. And for an internal monitor, the nurse counts and charts the pressure units. Lastly is rest. So this is that tone and time. The uterus should be soft to palpation between contractions for at least 60 seconds as the fetus needs this time to recover lost oxygen flow during those contractions. Now let's talk about normal contractions. And I want you guys to remember this rule of 60. First we have frequency. Contractions that are 2 to 3 minutes apart in active labor. So more than five contractions in 10 minutes is considered tachycally and that is bad but we will cover that in a moment. So duration should be around 60 seconds and intensity should be over 60 mm of mercury. Anything over 90 is a cause of concern. So lastly we have rest. We want about 60 seconds of rest in between contractions. Now in terms of complications there could be tachially and this is when there are over five contractions in 10 minutes. It's very dangerous as too many contractions could lead to fetal distress including hypoxia and reduced placental blood flow. As you can see, the normal uterine contraction pattern is less frequent than the tacky cy pattern. Now, switching gears to a popular memory trick before we get into the seven strips to know. So, line up the words ve and chop in a vertical fashion. So, the V is for variable decelerations. W or V-shaped dips are seen and that is very concerning as it indicates C chord compression and we want to change the mom's position. Next is E for early decelerations and this is where the fetal heart rate mirrors the contractions. Remember it's good to be early with dip to the party and this indicates head compression meaning a happy baby so the baby is ready for delivery. Next up is A for accelerations and this is that temporary increase in heart rate and remember this is okay as it's providing oxygen to the baby. Lastly is L for late decelerations and this is a lower heart rate after contractions. Now this one is very dangerous and is the one you must know for the enclelex since as you know the most deadly conditions are the most tested conditions and remember it's bad to show up late with dip to the party. So late D cells indicate P placental insufficiency which is P a big problem. So we use the memory trick roadie for interventions like the road to recovery. R is for repositioning the mom. O is oxygen via face mask. A alert the healthcare provider. Discontinue oxytocin and give toolytics. And lastly, I is increase those IV fluids. Remember oxytocin tells the uterus to contract, which means to induce labor. And toolytics like turbutilene help put that uterus in line and slow those turbulent contractions down. Now on to some Hessie questions. The first one asks what happens when oxytocin levels are elevated and this would be that uterine contractions will increase. Next is the nurse assesses fetal well-being during labor by monitoring which factor and this would be the response of the fetal heart rate to the uterine contractions. Unlock thousands of questions and exit prep lectures in our membership. Your shortcut to boosting your path to nursing success. Thanks, nurse Barbara. Okay, guys. Now, for the seven quick view strips here, this is what you're going to need to know for what is normal versus what is not normal. Then, we're going to dive into very nitty-gritty details. So, be sure to write this down. So, starting with normal expected findings. Number one is a normal fetal heart rate 110 to 160 beats per minute. And number two is accelerations. Remember this is a okay. Number three is early D cells. So the memory trick, it's good to be early to the party with those early DELs. Remember early dips are good. Now for what's not normal, please be sure to focus on this as it indicates fetal distress. So tacky or brada cardia that fast or slow heart rate late decelerations remember it's bad to be late to the party with that dip V for variable decelerations those are very bad and lastly sinosoidal tracing so the big memory trick it's bad to be late to the party with those late variable or absent D cells as late and deep V dips are bad don't be late with that chip dip and also absent or flat variability is also not good. Now, finally, let's review each in detail and focus on the critical nursing interventions that love to come up on select all that apply questions. So, first up is normal fetal heart rate between 110 and 160 beats per minute as mentioned before. So, please remember this is the heart rate that should be at baseline between contractions. This is the overall picture of where the fetal heart rate falls. Not with the minor speed ups in acceleration or slowdowns with those decelerations. As you can see, the baseline is a little bit hard to read here, but it lies around 130 beats per minute, which is normal range. Now, the second strip that you should know is accelerations. As mentioned before, these are the temporary increases in fetal heart rate or an acceleration in the heart rate. And remember this is a okay as it indicates good oxygenation and we have a happy baby. Now accelerations are not the same as number three early dels or those early decelerations. Early dels mere contractions with decreased fetal heart rate. Remember during contractions and these are okay. This is normal and to be expected with delivery as the uterus is contracting and trying to push that baby out. Now early D cells is caused from head compression during contractions and indicates that the baby is ready for delivery. The big intervention here is prepare for the delivery of the baby. So once again the memory trick it's good to be early with early D cells. So as he mentions which fetal heart rate tracing characteristics are considered reassuring or normal early decelerations either present or absent. Okay. Okay, now moving on to what's nonreassuring or very risky. So, please be sure to know the causes and interventions for each of these as these are the most tested. Starting with fetal tacocardia. This is an increase in the fetal heart rate over 160 beats per minute for over 10 minutes. Big key terms to write down. Anything less would be considered an acceleration. So, this is an early sign of fetal distress as mentioned by Hessie. This is also a compensatory mechanism when the baby undergoes a stressor from various causes that require the baby to use more oxygen. Now, if the cause is not identified and corrected, you'll start seeing a decrease in variability followed by late decelerations as the baby needs oxygen to survive just like adults. So causes include trauma to the mother, for example, a broken bone, maternal infection or fever, and remember these are the top two tested causes. We also have fetal anemia, dehydration, and even the use of stimulants, for example, cocaine. Now, in terms of intervention, oxygen can be given. IV fluids will help deliver more oxygen to the baby. And if the mother has a fever, we can give antipyetic meds. These are anti-fever medications. Now pulling from our simple nursing enlex question bank written by the people that actually wrote the enclelex. Here are the top missed test questions. Starting off with an ATI question. We have a client with a fractured wrist who is 36 weeks pregnant. Which of the following assessment items should the nurse prioritize? And the answer would be that the fetal heart rate is 210 beats per minute. Now a hessy question. While monitoring the fetal heart rate, the nurse notes tachi cardia which is a probable cause for this condition and this would be early signs of fetal distress. Next, we have a fetal heart rate baseline of 175 beats per minute. The nurse knows that this can be caused by which factor? Again, fetal tachicardia. Yes. This is why it's critical to know your key numbers. Anything over 160 is considered tacky. Thanks Barb. All right, now moving on to fetal brada cardia. This is where we have a decrease in fetal heart rate less than 110 beats per minute and remember it's always over 10 minutes. So anything less than 10 minutes would be considered a deceleration. Now causes include uteroplacental insufficiency. This is interface between the uterus and placenta which provides O2 to the fetus and other causes include umbilical cord prolapse, maternal hypotension that low blood pressure and even the use of analesic medications which makes the vital signs low and slow when given during labor. So for interventions the big memory trick is roadie like on the road to recovery. So R is for reposition the mom to sidelineing position. This is done in order to increase the mother's cardiac output, meaning more oxygen-rich blood coming out of mom's heart and cardiac output. Remember, never place the mother on her back or basically supine as this will compress the aorta and the inferior vennea causing hypotension and decrease placental perfusion. Now O is for oxygen via face mask. A is for alert the healthcare provider, the HCP, if the fetal heart rate does not return to baseline within five minutes. D is for discontinue oxytocin since oxytocin tells the uterus to contract. And lastly, I is increase IV fluids to increase blood volume and also to increase that cardiac output, which increases oxygen supply to the fetus. Remember, oxytocin tells the uterus to contract and to induce labor. So, stopping this infusion is priority. So, please be sure to write that down. So, Sandre says that there is a slowing of the fetal heart rate and loss of variability. The nursing action here would be to turn the client onto her side and give oxygen by face mask at 8 to 10 L per minute. And Hessie has two questions. Maternal cardiac output can be increased by which factor? This would be a change in position. Second, we have a sudden drop in fetal heart rate from its baseline of 125 down to 80. So, the nurse repositions the client, provides oxygen, increases the IV, and 5 minutes have passed and the fetal heart rate remains in the 80s. Which additional measure would the nurse take? And this would be to immediately notify that healthcare provider. Finally, we have Kaplan. There is an abrupt and rapid fluctuation in the fetal heart rate from a baseline of 90 beats per minute and back to baseline. The fluctuations in fetal heart rate occur with no relationship to the contraction pattern. So, which response by the nurse is best? So, this is a potential problem that requires a position change. So, yes, always the first intervention is to reposition the mother. All right. Now moving on to the critical findings. Variable decelerations. Remember these are very bad. We see abrupt decreases in fetal heart rate. We're talking really deep dips and really deep long drops in the fetal heart rate here. As you guys can see on the screen, see how deep those dips are. So, the key numbers to write down for your exams are fetal heart rate drops that are less than 30 seconds from the onset to baseline and 15 beats per minute below baseline for a total of 15 seconds to 2 minutes. So, please pause the screen and know those key numbers. Now, causes include umbilical cord compression, which is a big ENLEX tip, and this is critical since the oxygen tube is being compressed. If not quickly corrected, the baby can run out of oxygen. Another cause is decreased amniotic fluid. So we can increase that amniotic fluid with an amno infusion which we'll cover in a moment. Now interventions once again the memory trick roadie like the road to recovery. So R reposition the mom on sideline position. This is done to relieve umbilical cord compression and also take pressure off the mom's heart and increase that cardiac output. Now the mother can also be put into the knee chest position too but this is used more for prolapsed cord as you know O is for oxygen via face mask A is we alert the HCP the provider D is for discontinue oxytocin if it's being given and I increase those IV fluids. Now for amnneo infusion as mentioned before it is the installation of sterile saline into the amniotic cavity to refill the fluid that's lost. This is done if multiple position changes have not relieved the cord compression. Remember here, the uterus is like a big swimming pool for the baby, providing cushion to protect it from harm. So once that water breaks, the pool can drain out, leaving no cushion for the baby. So we simply add sterile saline to refill that pool. But what if we overfill that pool and cause too much pressure inside the uterus? So signs to report immediately for indications of overfilling. These are big and clelex tips. First is uterine resting tone that increases to 45 mm of mercury. Remember an overfilled uterus can cause too much pressure leading to complications like uterine rupture and increasing the risk for postpartum hemorrhage and even labor dystocia, a very slow labor which can cause more trauma. So, please be sure to write down those key words and big Enclelex tips. Now, moving on to late decelerations. Remember, these are the worst and this is the one to know for the enclelex. This is a decreased fetal heart rate after contractions with prolonged time before returning to baseline right around 60 seconds. Now, this is critical as it indicates that oxygenation is compromised. Big and clelex tip. The key is that the fetal heart rate continues to decrease beyond the end of that uterine contraction as seen here in the image. See how the lowest point the nater happens near the end of the contraction right before the fetal heart rate returns to baseline. Now causes include placental insufficiency also called uteroplacental insufficiency as mentioned by Hessie and other causes include uterine tachiccy big anlex tip. This is a common side effect of oxytocin which causes severe contractions like a big old cramp and this leads to reduced placental blood flow and even impaired fetal oxygen which is less O2 to the baby. So we always stop oxytocin for these key signs over five contractions in 10 minutes and late D cells. And another cause of late D cells is hypotension that low blood pressure. So for the memory trick remember it's bad to be late with late absent or even variable D cells. Now for the interventions again we use the memory trick roadie like the road to recovery here. So R we reposition mom to that sidelineing position to take pressure off the heart and increase that cardiac output. And again don't let the enclelex trick you here. Never supine position. So O was for oxygen via face mask. A is alert the HCP. And a big one here is D for discontinue oxytocin. Now once again this is priority as oxytocin can cause those late D cells. So again remember oxytocin tells the uterus to contract and to induce labor. And lastly I is for IV fluids like normal saline or lactated ringers. Basically we want isotonic fluids to increase that blood pressure. And we always prepare for a C-section if late D cells persist after these interventions are implemented. So now for a top missed enclelex question. A new nurse is evaluating the fetal monitoring strip of a client in labor who is receiving an oxytocin infusion. Which of the following actions should the nurse take next? So let's click on the exhibit. OMG, this is definitely late decelerations. So let's look at the options first. Do we slow the oxytocin infusion? No. This is wrong. So, we want to stop the oxytocin infusion, not slow it down. So, don't let the enclelex trick you here. Over 60% of students get this wrong. We always want to stop the oxytocin infusion if it's causing late D cells. The next option is to reposition the client to the left or right side. And this is correct. Amnoinfusion. This is wrong. Don't let the enclelex trick you. This is only for variable D cells. And the last three options are correct. Oxygen by face mask, initiating an IV bololis of.9% saline, and then notifying the provider and preparing turbutylene. Yes, we do anticipate that provider to order turbutilene as this helps slow down those turbulent contractions. Get a full breakdown of what you need to pass the enclelex with our enlex review lecture series and live cram sessions led by myself and industry experts. Now for Hessie, we're talking about oxytocin induction. So the last five contractions, the fetal heart rate has fallen below the baseline and then returns to baseline in 20 to 30 seconds after the end of the contraction. Which actions must be taken by the nurse? So, we want to contact the health care provider, stop the infusion of oxytocin, increase the infusion of the mainline IV, apply oxygen by face mask, and reposition the client. And Kaplan mentions a fetus is experiencing distress if which heart rate pattern is observed. So, this would be late decelerations. Now, we have ATI. So, which of the following interventions would be performed after examining this fetal monitoring strip? Okay, so looking at the strips, it looks like late decelerations. So we want to discontinue the oxytocin and run the IV fluids wide open. Thanks so much, nurse Barb. All right, guys. The last strip here is sinoidal fetal heart rate. And this is a very bad finding. This is another one to know for the enlex. And remember, many students get this wrong. This is a pattern characterized by repetitive wavelike fluctuations or hills with no variability, basically no wiggling and no response to contractions. Again, this is a critical finding requiring immediate intervention as the baby can die from lack of oxygen. So for the causes, the mother can have an abdominal trauma, for example, a fall or a motor vehicle accident which can lead to fetal blood loss or even anemia and even Rh incompatibility and it could cause hemolyis of the fetal RBC's. So in terms of intervention, it only includes an emergency cacaian section also called a crash c-section. So we must prepare for an expedited birth. Okay. And now to wrap this up for a top missed enclelex question. Over 70% of students got this wrong. So please listen close. The nurse is observing the fetal heart rate tracing of four clients. Which pattern would be the most concerning? So let's look at them here. The first one up, we see early decelerations. As you can see, they mirror contractions and have a shallow B-shaped appearance. Okay, on to the second strip. Now this one looks like variable decelerations with very deep dips. Now this is very concerning with abrupt decreases in that fetal heart rate. All right. Now this third strip looks definitely like sinosoidal fetal heart rate. So just look at those waves on top with no response to contraction. So this one is the most deadly by far. All right. But the last one here now this one looks like fetal tacicardia as the heart rate is really high. So, which one is the most deadly? If I had to choose, option two and three would be the most critical here, but option three would be the most concerning as it's the most deadly, so it would be the most correct. Thanks for watching. Did you know you can unlock beautifully handcrafted study guides packed with key points and memory tricks from all our videos? 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