Physiological Integrity Q 19
The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:
A. Reposition the monitor
B. Turn the client to her left side
C. Ask the client to ambulate
D. Prepare the client for delivery
Correct Answer: B. Turn the client to her left side
The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. A slow heart rate, or bradycardia, may indicate the baby is not getting enough oxygen delivery to the brain. A fast heart rate, or tachycardia, may indicate oxygen deprivation. There is an acceptable range of acceleration and deceleration – or speeding up and slowing down – of fetal heart rates during contractions and labor.
Option A: Repositioning the monitor is not indicated at this time. Obstetricians and nurses must carefully review fetal monitor strips throughout labor and delivery to ensure fetal heart tones are reassuring and the baby is getting enough oxygen. If non-reassuring conditions occur, appropriate and timely actions must be taken.
Option C: Asking the client to ambulate is not the best action for clients experiencing bradycardia. Generally, nursing interventions are attempted first to restore normal oxygenation to the baby. These include the administration of supplemental oxygen, changes in maternal position, increasing intravenous fluids, and the administration of medications that subdue contractions and maximize placental blood flow.
Option D: There is no data to indicate the need to move the client to the delivery room at this time. If fetal heart tones remain non-reassuring despite nursing interventions, the fetus should be delivered by emergency cesarean section. Emergency cesarean section should be performed within 5 to 30 minutes depending on the circumstances.