Maternity Nursing: Antepartum Q 48
A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:
A. Noting if the heart rate is greater than 140 BPM.
B. Placing the diaphragm of the Doppler on the mother's abdomen.
C. Performing Leopold’s maneuvers first to determine the location of the fetal heart.
D. Palpating the maternal radial pulse while listening to the fetal heart rate.
Correct Answer: D. Palpating the maternal radial pulse while listening to the fetal heart rate.
The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate.
Option A: As cardiac output increases, the heart rate at rest speeds up from a normal prepregnancy rate of about 70 beats per minute to 80 or 90 beats per minute. During exercise, cardiac output and heart rate increase more when a woman is pregnant than when she is not.
Option B: One type of monitor is a Doppler ultrasound device. It’s often used during prenatal visits to count the baby’s heart rate. It may also be used to check the fetal heart rate during labor. The healthcare provider may also check the baby’s heart rate continuously during labor and birth. To do this, the ultrasound probe (transducer) is fastened to the belly. It sends the sounds of the baby’s heart to a computer.
Option C: Leopold’s maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.