The laboring patient's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 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 patient into Fowler's position.
1
Rationale 1: 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.
Rationale 2: No oxygen is necessary.
Rationale 3: There is no indication that delivery will be occurring soon.
Rationale 4: There is no need to put the patient in Fowler's position.
You might also like to view...
You are caring for a patient admitted with angina who is scheduled for a cardiac catheterization. The patient is anxious and asks you about the reason for this test. What is your best response?
A) "A cardiac catheterization is most commonly done to assess coronary artery patency." B) "A cardiac catheterization is most commonly done to detect myocardial ischemia." C) "A cardiac catheterization is most commonly done to evaluate cardiovascular response to stress." D) "A cardiac catheterization is most commonly done to evaluate cardiac electrical activity."
An infant with a congenital heart defect is to receive a dose of palivizumab (Synagis). What is the purpose of this?
a. Prevent RSV infection. b. Prevent secondary bacterial infection. c. Decrease toxicity of antiviral agents. d. Make isolation of infant with RSV unnecessary.
The nurse assesses four clients before knee surgery. Which client is most likely to have the surgery delayed?
1. A 10-pack-year history of smoking 2. Left calf pain, redness, and swelling 3. Upper respiratory infection last month 4. A low-normal serum hemoglobin level
Order: 600 mL D5W IV to infuse in six hours. At what rate in mL/h will you set the pump?
1. 100 mL/hr 2. 10 mL/hr 3. 1.7 mL/hr 4. 60 mL/hr