Author Question: A new nurse is assessing baseline fetal heart tones (FHTs) by auscultation and notes that the heart ... (Read 39 times)

Caiter2013 · **on:** Jun 28, 2018

A new nurse is assessing baseline fetal heart tones (FHTs) by auscultation and notes that the heart rate increased during a contraction from 140 to 158. What action by the nurse preceptor is best?

A.
Gather equipment for internal FHT monitoring.
B.
Have the nurse document FHT of 140/158.
C.
Instruct the nurse to assess FHT between contractions.
D.
Tell the nurse to count only for 30 seconds.

Question 2

A nurse assesses the fetal heart rate at 188 beats/minute in a woman who is receiving a tocolytic medication to halt contractions. Which action should the nurse take first?

A.
Assess the maternal temperature and call the primary care provider.
B.
Document the findings in the patient's chart.
C.
Have the woman get up and walk or change position.
D.
Perform a vaginal exam to assess for cord compression.

kswal303 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C
Baseline fetal heart tones can only be assessed during the absence of uterine activity. The preceptor should instruct the new nurse to listen for FHTs between contractions. The woman does not need internal FHT monitoring based on this assessment. The reading is inaccurate, so the nurse preceptor should not have the new nurse document these findings and this method (140/158) is not appropriate. The new nurse may have to count fetal heart tones for only 30 seconds if the woman is having frequent contractions, although assessing for 1 minute is the most accurate method.

Answer to Question 2

ANS: A
Causes of fetal tachycardia include fetal hypoxia, maternal fever, maternal medications (such as parasympathetic drugs and tocolytic drugs), infection, fetal anemia, and maternal hyperthyroidism. The nurse should quickly assess the maternal temperature and call the provider, as the tocolytic medication may need to be slowed or stopped. The findings do need to be documented, but further action is needed. The woman should not get up and walk, as this will further stimulate the fetus. Checking for cord compression is an important intervention with fetal bradycardia.