A nurse assesses fetal heart tones at 100 beats/minute. Which action by the nurse takes priority?
A.
Administer 100% oxygen.
B.
Assess the maternal heart rate.
C.
Notify the primary care provider.
D.
Turn the woman on her left side.
ANS: B
Causes of fetal bradycardia include late fetal hypoxia, medications (beta blockers), maternal hypotension, prolonged umbilical cord/fetal head compression, fetal bradyarrhythmias, uterine hyperstimulation, abruptio placentae, uterine rupture or vasa previa, or vagal stimulation during the second stage of labor. However, it is also possible that the maternal heart tones are mistakenly counted as fetal heart tones. The first action by the nurse is to assess the maternal heart rate to confirm that it is not being counted as the fetal heart rate. This is done whether the nurse is using a fetoscope or external fetal monitoring.
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