QUESTION: "A 34-year-old multigravida at 36 weeks' gestation is diagnosed with preterm labor. The client has experienced one infant death due to preterm birth at 28 weeks' gestation. On admission to the antenatal unit, the nurse determines that the fetal heart rate is 140 bpm. Which of the following should the nurse do next?"
CHOICES
( X ) a.) Administer oxygen by mask at 8 L/minute.
( X ) b.) Notify the client's physician immediately.
( O ) c.) Continue monitoring the client and fetus.
( X ) d.) Recheck the fetal heart rate again in 5 minutes.
RATIONALE: Fetal heart rate is normally between 120 and 160 bpm. The finding of a fetal heart rate at 140 bpm is within this normal range. Therefore, the nurse should continue to monitor the client and fetus. A fetal heart rate of 140 bpm is within the normal range of 120 to 160 bpm. Neither the fetus nor the mother is in any distress. Therefore, oxygen is not necessary. A fetal heart rate of 140 bpm is not an abnormal reading, so there is no need to notify the physician. Because the fetal heart rate is within normal parameters, there is no indication that fetal heart rate needs to be checked again in 5 minutes. However, continued monitoring based on agency policy is warranted. In some institutions, continuous fetal heart rate monitoring is performed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
