A nurse assesses the fetal heart rate at 188 beats/minute in a woman who is receiving a tocolytic medication to halt contractions. Which action should the nurse take first?
A.
Assess the maternal temperature and call the primary care provider.
B.
Document the findings in the patient's chart.
C.
Have the woman get up and walk or change position.
D.
Perform a vaginal exam to assess for cord compression.
ANS: A
Causes of fetal tachycardia include fetal hypoxia, maternal fever, maternal medications (such as parasympathetic drugs and tocolytic drugs), infection, fetal anemia, and maternal hyperthyroidism. The nurse should quickly assess the maternal temperature and call the provider, as the tocolytic medication may need to be slowed or stopped. The findings do need to be documented, but further action is needed. The woman should not get up and walk, as this will further stimulate the fetus. Checking for cord compression is an important intervention with fetal bradycardia.
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