During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate is 136 beats per minute. The nurse's next action should be to:
a. Document the results, which are within normal range.
b. Take the maternal pulse to verify these findings as the uterine souffle.
c. Have the patient change positions and count the FHTs again.
d. Immediately notify the physician for possible fetal distress.
ANS: A
The normal fetal heart rate is between 110 and 160 beats per minute. The nurse should document the results as within the normal range. The other options are not correct.
You might also like to view...
Which of the following patients demonstrates the clearest indication for treatment with prednisone?
A) A 66-year-old woman whose history of smoking has culminated in a diagnosis of emphysema B) A 70-year-old man whose rheumatoid arthritis has not responded to OTC pain relievers C) A 12-year-old boy whose long-standing fatigue and malaise have been attributed to leukemia D) A 50-year-old woman who is being treated for hypertension with a diuretic and an ACE inhibitor
A postoperative client is transferred to the medical-surgical unit from the intensive care unit (ICU). The client asks the assigned nurse why unlicensed assistive personnel (UAP) help with range-of-motion exercises. Which is the best response by the nurse
A) "Your condition has improved so I delegated that part of your care to the UAP." B) "You do not need me to ambulate you." C) "The charge nurse made the decision to have the UAP assist you when walking." D) "I assigned all of your care to the UAP."
The staff development instructor is preparing material for an in-service on role conflict in nurses. If the instructor provides the information according to consequences, in which order should this material be provided?
1. Role stress 2. Public image 3. Role discrepancy 4. Role value orientation
What do diagnosis-related groups (DRGs) establish?
1. The nursing care plan 2. Pretreatment diagnosis billing categories and fee schedule 3. Private health insurance premiums 4. The need for the primary care physician to be consulted