A nurse assesses fetal heart tones at 100 beats/minute. Which ...

[Bob-Dole]

A nurse assesses fetal heart tones at 100 beats/minute. Which action by the nurse takes priority?
 
  A.
  Administer 100 oxygen.
  B.
  Assess the maternal heart rate.
  C.
  Notify the primary care provider.
  D.
  Turn the woman on her left side.

Question 2

A nurse has assessed baseline fetal heart tones (FHTs) by auscultation and documents a funic souffl of 158 beats/minute and a uterine souffl of 90 beats/minute.
 
  When the first nurse gives a handoff report to an oncoming nurse, what can the second nurse conclude from this information?
  A.
  Fetal and maternal heart rates are outside of normal limits.
  B.
  Fetal and maternal heart rates are within normal limits.
  C.
  The second nurse cannot distinguish between fetal and maternal heart rates.
  D.
  There is a great deal of fetal heart rate variability between contractions.

[Mochi]

Answer to Question 1

ANS: B
Causes of fetal bradycardia include late fetal hypoxia, medications (beta blockers), maternal hypotension, prolonged umbilical cord/fetal head compression, fetal bradyarrhythmias, uterine hyperstimulation, abruptio placentae, uterine rupture or vasa previa, or vagal stimulation during the second stage of labor. However, it is also possible that the maternal heart tones are mistakenly counted as fetal heart tones. The first action by the nurse is to assess the maternal heart rate to confirm that it is not being counted as the fetal heart rate. This is done whether the nurse is using a fetoscope or external fetal monitoring.

Answer to Question 2

ANS: B
Fetal heart tones (funic souffl) should be in the range of 110 to 160 beats/minute, so FHTs are within normal limits. The maternal heart rate (uterine souffl) is also within normal limits.

[Bob-Dole]

Thanks for the timely response, appreciate it

[irishcancer18]

Excellent