Author Question: The nurse performs a vaginal examination to determine labor progress. She notes that the FHR, as ... (Read 69 times)

bclement10 · **on:** Jun 28, 2018

The nurse performs a vaginal examination to determine labor progress. She notes that the FHR, as indicated on EFM, rises approximately 30 beats/minute above baseline for about 60 seconds. The nurse recognizes that:

a. This is a normal response of the fetus to the vaginal examination and requires documentation only.
b. This is an early sign of fetal infection and should be reported to the health care provider.
c. The laboring woman must be getting a fever to cause the FHR to rise like that.
d. This is an indication that the fetus may have a nuchal cord.

Question 2

When the nurse is caring for a labor patient who is on continuous electronic fetal monitoring, the baseline fetal heart rate is 150 beats/minute. Which pattern would alert the nurse to possible fetal distress?

a. A baseline variability of 20 beats/minute
b. Fetal heart rate of 170 beats/minute during vaginal examinations
c. Heart rate of 115 beats/minute at the beginning of a uterine contraction
d. Heart rate of 100 beats/minute beginning at the peak of a uterine contraction

emilymalinowski12 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
Accelerations are brief, temporary increases in fetal heart rate associated with fetal movement, vaginal examinations, uterine contractions, fundal pressure, and breech presentations. Accelerations are a reassuring FHR pattern and a sign of fetal well-being.

Answer to Question 2

ANS: D
A decrease in FHR that begins at the peak of a contraction is often associated with uteroplacental insufficiency.