You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?
a) Start pitocin
b) Insert a Foley catheter
c) Call for help.
d) Notify the care provider immediately
a) Notify the care provider immediately
A new client and her partner arrive on the labor, delivery, recovery, and postpartum unit for the birth of their first child. You apply the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby’s heart rate should be. Your best response is:
a) “Your doctor will explain all of that later.”
b) “The top line graphs the baby’s heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor.”
c) “Don’t worry about that machine; that’s my job.”
d) “The top line graphs the baby’s heart rate, and the bottom line lets me know how strong the contractions are.”
A nurse might be called on to stimulate the fetal scalp:
a) In response to tocolysis.
b) To elicit an acceleration in the fetal heart rate (FHR).
c) As part of fetal scalp blood sampling.
d) In preparation for fetal oxygen saturation monitoring
a) To elicit an acceleration in the fetal heart rate (FHR).
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:
a) Change in position.
b) Intravenous analgesic.
c) Regional anesthesia.
d) Oxytocin administration.
Change in position.
According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR):
a) Before and after ambulation and rupture of membranes.
b) Every 15 minutes in the active phase of the first stage of labor in the absence of risk factors
c) More often in a woman’s first pregnancy
d) Every 20 minutes in the second stage, regardless of whether risk factors are present.
Which fetal heart rate (FHR) finding would concern the nurse during labor?
a) Early decelerations
b) Accelerations with fetal movement
c) Late decelerations
d) An average FHR of 126 beats/min
Sign up for free and study better.
Get started today!