The nurse admits the client to the obstetrician's office for a routine prenatal visit. The nurse obtains the client's vital signs and fetal heart tones

Question

When the vital signs are assessed, the nurse finds the fetal heart rate and client's pulse are the same, at 92 beats per minute. The nurse interprets this to indicate: 1. The fetus is in distress, and requires immediate intervention.
2. The fetus and mother are both doing well.
3. The fetal heart tones should be reassessed.
4. The mother should be admitted to the Labor and Delivery unit immediately.

Answer 1

3
Rationale: When the fetal heart tone is the same as the mother's, the nurse should reassess fetal heart tones, because it is highly likely the nurse heard placental circulation and not fetal heart tones. If the nurse determines the fetal heart rate is actually 92 beats per minute after re-evaluation, the physician should be notified.