The practical nurse (PN) is obtaining fetal heart rates on four antepartum clients in their third trimester of pregnancy. Which fetal heart rate should be reported to the registered nurse (RN) immediately?

A. Encourage the use of incontinence briefs: While briefs provide protection and maintain hygiene, they do not promote bowel control or help the client regain continence. This intervention is supportive but does not actively address bowel training goals.

B. Insert a rectal tube at specified intervals: Rectal tubes are invasive and typically reserved for acute, severe cases of fecal retention or obstruction. Routine use for bowel training is inappropriate and can cause discomfort or complications.

C. Administer a glycerin suppository 15 minutes after meals: Suppositories can stimulate bowel movements, but timing is crucial. Administering immediately after meals may not coincide with the client’s natural gastrocolic reflex, reducing effectiveness and cooperation with the training regimen.

D. Assist to a bedside commode 30 minutes after meals: This intervention leverages the gastrocolic reflex, which naturally increases bowel motility after eating. Assisting the client to the commode at this time supports regular, predictable bowel movements and is a central strategy in establishing a bowel training program.

A. Red, hot, and swollen joints: While these signs may indicate inflammation or early rheumatic complications, they are not immediately life-threatening. They require assessment and monitoring, but urgent intervention is not indicated unless systemic symptoms worsen.

B. Pulse oximetry of 88% O2 saturation: An oxygen saturation of 88% is critically low and indicates hypoxemia, which can compromise tissue oxygenation and organ function. This finding warrants immediate intervention to stabilize the child’s respiratory status and prevent further deterioration.

C. Slightly raised rash with ragged edges: A mild rash may be associated with strep-related skin manifestations or other benign conditions. It requires assessment but does not pose an immediate threat to the child’s health.

D. Heart rate 110 beats/minute: A heart rate of 110 in a child can be within the normal range depending on age and anxiety level. While it should be monitored, it does not necessitate immediate intervention compared to significant hypoxemia.