A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/min. Which of the following nursing actions is appropriate?
1. Document the findings.
2. Notify the physician.
3. Inform the client that everything is normal and fine.
4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.
2
Rationale: The fetal heart rate should be 120 to 160 beats/min during pregnancy. A fetal heart rate of 90 beats/min would require that the physician be notified and the client be further evalu-ated. The other options are inappropriate. "Document the findings" and "inform the client that everything is normal and fine" are comparable or alike and can be eliminated first. "Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate" is an inaccurate nursing action.
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