A new nurse is assessing baseline fetal heart tones (FHTs) by auscultation and notes that the heart rate increased during a contraction from 140 to 158. What action by the nurse preceptor is best?
A.
Gather equipment for internal FHT monitoring.
B.
Have the nurse document FHT of 140/158.
C.
Instruct the nurse to assess FHT between contractions.
D.
Tell the nurse to count only for 30 seconds.
ANS: C
Baseline fetal heart tones can only be assessed during the absence of uterine activity. The preceptor should instruct the new nurse to listen for FHTs between contractions. The woman does not need internal FHT monitoring based on this assessment. The reading is inaccurate, so the nurse preceptor should not have the new nurse document these findings and this method (140/158) is not appropriate. The new nurse may have to count fetal heart tones for only 30 seconds if the woman is having frequent contractions, although assessing for 1 minute is the most accurate method.
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