The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction
What nursing action is best? 1. Document the fetal heart rate.
2. Apply oxygen via mask at 10 liters.
3. Prepare for imminent delivery.
4. Assist the client into Fowler's position.
1. Document the fetal heart rate.
Rationale:
The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. The fetal heart rate tracing is normal; oxygen is not indicated. There is no indication that delivery will be occurring soon. The fetal heart rate tracing is normal, no intervention is necessary. The client does not need to be assisted into the Fowler's position.
You might also like to view...
The nurse is documenting the pediatrician's assessment of a female patient. When assessing Tanner's stages of breast development there is elevation of papilla only. What stage of development will the nurse document?
a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
A client comes to the clinic with the complaint that he has been ill for several weeks but do not have insurance and have delayed care
What does the LPN understand about the overall healthcare reform goals that will address issues such as this client? A) The goal of healthcare reform is to provide care to women, infants, and children. B) The goal of healthcare reform is to provide more healthcare programs to address illness. C) The goal of healthcare reform is to provide quality healthcare for those that can afford it. D) The goal of healthcare reform is to provide affordable healthcare to more citizens.
Which assessment findings indicate a potential self-concept dysfunction? Select all that apply
A) depersonalization B) feelings of inadequacy C) preoccupation with affected body part D) inability to make decisions E) refusal to make eye contact
The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. What should the nurse do to support the client at this time? Select all that apply
1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby.