The nurse auscultates fetal heart tones on a woman in her third trimester of pregnancy and counts a heart rate of 92 beats/minute. Which action by the nurse is best?
A.
Apply oxygen at 6 L/minute.
B.
Assess the maternal heart rate.
C.
Document the findings in the chart.
D.
Turn the woman on her left side.
ANS: B
The normal fetal heart rate is 110-160 beats/minute. If the nurse assesses a lower rate, the maternal heart rate should be assessed. If the two heart rates are similar, the nurse has inadvertently counted only the maternal rate. The nurse should attempt to locate the fetal pulse and try again. If the two rates differ (i.e., the fetal heart rate is truly 92 beats/minute), the nurse should place the woman on her left side, apply oxygen by mask, and seek assistance. Documentation should always occur.
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