You are evaluating the fetal monitor tracing of your client, who ...

[c0205847]

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80.
 
  You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?
  a. Scream for help.
  b. Insert a Foley catheter.
  c. Start Pitocin.
  d. Notify the care provider immediately.

Question 2

Fetal well-being during labor is assessed by:
 
  a. The response of the fetal heart rate (FHR) to uterine contractions (UCs).
  b. Maternal pain control.
  c. Accelerations in the FHR.
  d. An FHR above 110 beats/min.

[reversalruiz]

Answer to Question 1

ANS: D
To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. Pitocin may place additional stress on the fetus.

Answer to Question 2

ANS: A
Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR above 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information would be needed to determine fetal well-being.

[c0205847]

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