The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction
What nursing action is best? 1. Document the fetal heart rate.
2. Apply oxygen via mask at 10 liters.
3. Prepare for imminent delivery.
4. Assist the client into Fowler's position.
1
Rationale:
1. The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary.
2. The fetal heart rate tracing is normal; no intervention is necessary.
3. There is no indication that delivery will be occurring soon. The fetal heart rate tracing is normal.
4. The fetal heart rate tracing is normal; no intervention is necessary.
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