The nurse observes the following data on an electronic fetal monitor attached to a client in the active phase of the first stage of labor: fetal heart rate baseline, 125 to 140 bpm, three accelerations over the course of 20 minutes, moderate variability
What is the priority action based on these findings?
a. Document the findings.
b. Contact the health care provider.
c. Increase the rate of the existing IV to 200 mL/hr as per the standing prescription.
d. Place oxygen via a rebreather mask at 10 L/min as per the standing prescription.
ANS: A
The findings are all within normal limits for the laboring client. Accelerations are usually a reassuring sign. Normal fetal heart rate is 110 to 160 bpm and of moderate variability; amplitude range of 6 to 25 bpm is desirable. No intervention is required because the pattern suggests that the fetus has adequate reserves to tolerate intrapartum stressors.
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