Maternity Nursing: Antepartum Q 46
A nurse is performing an assessment of a client who is scheduled for cesarean delivery. Which assessment finding would indicate a need to contact the physician?
A. Fetal heart rate of 180 beats per minute.
B. White blood cell count of 12,000.
C. Maternal pulse rate of 85 beats per minute.
D. Hemoglobin of 11.0 g/dL.
Correct Answer: A. Fetal heart rate of 180 beats per minute.
A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification.
Option B: WBC count increases to 6 to 16 million/mL and can be as high as 20 million/mL during and shortly after labor.
Option C: Initially, the increase in cardiac output is due to an increase in stroke volume. As the stroke volume decreases towards the end of the third trimester, an increase in heart rate acts to maintain the increased cardiac output.
Option D: By full-term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.