Maternity Nursing: Intrapartum Q 44
A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client’s abdomen. After the attachment of the monitor, the initial nursing assessment is which of the following?
A. Identifying the types of accelerations
B. Assessing the baseline fetal heart rate
C. Determining the frequency of the contractions
D. Determining the intensity of the contractions
Correct Answer: B. Assessing the baseline fetal heart rate
Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority.
Option A: The FHR recordings may be interpreted as reassuring, nonreassuring or ominous, according to the pattern of the tracing. Reassuring patterns correlate well with a good fetal outcome, while nonreassuring patterns do not. Evaluation of fetal well-being using fetal scalp stimulation, pH measurement, or both, is recommended for use in patients with nonreassuring patterns.
Option C: Frequency is based on the time between the start of one contraction and the start of the next contraction. Time the frequency of contractions by noting the time when one contraction starts and the time when the next contraction starts.
Option D: The intensity of the contractions can be estimated by touching the uterus. The relaxed or mildly contracted uterus usually feels about as firm as a cheek, a moderately contracted uterus feels as firm as the end of the nose, and a strongly contracted uterus is as firm as the forehead.