When using intermittent auscultation (IA) for fetal heart rate, nurses should be aware that:
a. They can be expected to cover only two or three clients when IA is the primary method of fetal assessment.
b. The best course is to use the descriptive terms associated with electronic fetal monitoring (EFM) when documenting results.
c. If the heartbeat cannot be found immediately, a shift must be made to EFM.
d. Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.
ANS: D
Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if ultrasound is used to help locate the heartbeat. When used as the primary method of fetal assessment, auscultation requires a nurse-to-client ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate.
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