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The nurse auscultates the FHR and determine a rate of 152. Which action by the nurse is appropriate?

Reassess the FHR in 5 minutes

Take the client's temperature

Inform client that the rate is normal

Immediately report FHR to the physician

Answer and Explanation

The Correct Answer is C

A. Reassess the FHR in 5 minutes:
Not necessary unless abnormal; 152 bpm is normal.

B. Take the client’s temperature:
No indication of maternal fever; unnecessary.

C. Inform client that the rate is normal:
Normal FHR is 110–160 bpm; slight variation like 152 is acceptable.

D. Immediately report FHR to physician:
Not needed for a normal FHR.

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Correct Answer is C

Explanation

Based on the image provided: The baby's head is down (cephalic or vertex presentation). The back of the baby's head (occiput) is pointing toward the mother's left and front (anterior).

A. Glucose challenge test B. Amniocentesis C. Alpha Fetal Protein (AFP) D. Group beta streptococcus

Correct Answer is C

Explanation

A. Glucose challenge test: Done at 24–28 weeks to screen for gestational diabetes.

B. Amniocentesis: Can be done around 15–20 weeks but is more invasive and not routine for all clients.

C. Alpha Fetal Protein (AFP): AFP screening occurs around 14–18 weeks to assess risk for neural tube defects and chromosomal anomalies.

D. Group beta streptococcus: Screened at 35–37 weeks.

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The nurse auscultates the FHR and determine a rate of 152. Which action by the nurse is appropriate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Explanation

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