The nurse is taking the vital signs of a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action?
The nurse is taking the vital signs of a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action?
A. Notify the healthcare provider
[6%]
B. Document and continue to monitor
[66%]
C. Place the mother on her left side
[26%]
D. Administer 100% FiO2 via face mask
[2%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Labor/Delivery
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Analysis
Explanation
Choice B is correct. Since the nurse has noted a reassuring sign of the fetal heart rate, it is appropriate for her to document the findings and continue to monitor the mother. If the nurse had noticed a non-reassuring sign, other interventions would be necessary.
Choice A is incorrect. The nurse has observed an acceleration in the fetal heart rate, which is an increase in fetal heart rate by 15 bpm above the baseline. An acceleration lasts about 10-15 seconds and then the heart rate returns to baseline. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip. The nurse does not need to report this to the healthcare provider.
Choice C is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require repositioning of the mother to the left side. Repositioning the mother to the left-lateral position will be needed if a non-reassuring sign (e.g. fetal bradycardia, late decelerations) is noted.
Choice D is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require administration of 100% FiO2 via face mask.
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