The nurse is preparing to assess the fetus of a laboring client. Which should the nurse perform first?
1. Place the client into a left lateral position.
2. Perform the Leopold maneuver to determine fetal position.
3. Dry the maternal abdomen before using the Doppler.
4. Count the fetal heart rate for 30 seconds and multiply by 2.
2
Explanation:
1. The fetal heart tone assessment should be performed while the client is either supine with a lateral tilt or while in left lateral position.
2. Leopold maneuvers are performed first to determine where to listen for fetal heart tones. This is the first step so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided.
3. Prior to using the Doppler device, a water-based gel is applied to the skin.
4. Although this is how to auscultate the fetal heart rate, it is better to perform Leopold maneuvers to determine fetal position so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided.
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