The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate?
a. Inform the mother that the rate is normal.
b. Reassess the fetal heart rate in 5 minutes because the rate is too high.
c. Report the fetal heart rate to the physician or nurse-midwife immediately.
d. Tell the mother that she is going to have a boy because the heart rate is fast.
ANS: A
The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.
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