Maternity Nursing: Intrapartum Q 22
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate?
A. Encourage the client’s coach to continue to encourage breathing exercises.
B. Encourage the client to continue pushing with each contraction.
C. Continue monitoring the fetal heart rate.
D. Notify the physician or nurse-midwife.
Correct Answer: D. Notify the physician or nurse-midwife.
A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse-midwife needs to be notified.
Option A: Steps can be taken to help the fetus get more oxygen, such as having the mother change position. If these procedures do not work, or if further test results suggest the fetus has a problem, the ob-gyn or other health care professional may decide to deliver right away.
Option B: Uterine contractions also may be monitored with a special tube called an intrauterine pressure catheter that is inserted through the vagina into the uterus. Internal monitoring can be used only after the membranes of the amniotic sac have ruptured.
Option C: Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed.