What is the first action that the nurse should take when assessing the fetal heart rate (FHR) of a woman at 30 weeks of gestation and finding a rate of 82 beats/min?
Recognize that the rate is within normal limits and record it.
Notify the physician.
Assess the woman's radial pulse.
Allow the woman to hear the heartbeat.
The Correct Answer is C
Choice A reason: This is not the correct action, as the rate is not within normal limits. A normal FHR at 30 weeks of gestation is between 110 and 160 beats/min. A rate of 82 beats/min is considered bradycardia (slow heart rate), which can indicate fetal distress or hypoxia (low oxygen).
Choice B reason: This is not the first action, but it may be necessary after confirming the FHR. The nurse should first rule out the possibility of a maternal-fetal heart rate confusion, which can occur when the maternal heart rate is mistakenly counted as the FHR. This can happen if the Doppler or the electronic fetal monitor is placed too close to the maternal pulse or if the maternal heart rate is unusually slow².
Choice C reason: This is the correct action, as it can help differentiate between the maternal and the fetal heart rate. The nurse should assess the woman's radial pulse at the same time as listening to the FHR and compare the rates and rhythms. If the rates are the same or very close, it is likely that the nurse is hearing the maternal heart rate instead of the FHR. If the rates are different, it is likely that the nurse is hearing the FHR and that the fetus has bradycardia.
Choice D reason: This is not the correct action, as it may cause unnecessary anxiety or distress for the woman. The nurse should not allow the woman to hear the heartbeat until the FHR is confirmed and the cause of the bradycardia is determined. The nurse should also explain the situation to the woman and provide reassurance and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Limiting fluid intake throughout the day is not recommended, as dehydration can worsen nausea and vomiting. Instead, pregnant women should sip fluids gradually throughout the day to maintain hydration. Proper hydration supports digestion and helps prevent complications like electrolyte imbalances. Clinical guidelines emphasize the importance of maintaining adequate fluid intake during pregnancy
Choice B reason: Drinking a glass of water with a fat-free carbohydrate before getting out of bed in the morning is a good strategy to prevent nausea and vomiting, as it can stabilize the blood sugar level and prevent an empty stomach. However, it is not the best answer, as it does not address the dietary needs throughout the day.
Choice C reason: Increasing the intake of high-fat foods is not recommended, as it can worsen nausea and vomiting. High-fat foods are harder to digest and can cause gastric irritation and reflux. The pregnant woman should choose low-fat, bland, and easy-to-digest foods.
Choice D reason: Eating small, frequent meals every 2 to 3 hours is the best approach to managing nausea and vomiting during pregnancy. This strategy helps stabilize blood sugar levels and prevents the stomach from becoming too empty or too full, both of which can trigger nausea. Clinical guidelines widely support this dietary adjustment as a primary intervention for nausea and vomiting in pregnancy
Correct Answer is C
Explanation
Choice A reason: Anxiety due to hospitalization is not a likely cause of the signs reported by the patient. Anxiety can cause some symptoms, such as headache, palpitations, or sweating, but it does not cause visual changes or epigastric pain. Anxiety is also not a common complication of pregnancy-induced hypertension, which is a condition characterized by high blood pressure and protein in the urine.
Choice B reason: Effects of magnesium sulfate are not a likely cause of the signs reported by the patient. Magnesium sulfate is a medication used to prevent seizures and lower blood pressure in patients with pregnancy-induced hypertension. It can cause some side effects, such as flushing, nausea, or drowsiness, but it does not cause headache, visual changes, or epigastric pain. In fact, magnesium sulfate can help relieve these symptoms by reducing the cerebral edema and vasospasm caused by pregnancy-induced hypertension.
Choice C reason: Worsening disease and impending convulsion are the most likely cause of the signs reported by the patient. These signs indicate that the patient is developing severe preeclampsia or eclampsia, which are life-threatening complications of pregnancy-induced hypertension. Preeclampsia is characterized by high blood pressure, protein in the urine, and signs of organ damage, such as headache, visual changes, epigastric pain, or decreased urine output. Eclampsia is the occurrence of seizures in a patient with preeclampsia. These conditions can lead to stroke, bleeding, placental abruption, or fetal distress, and require immediate medical attention.
Choice D reason: Gastrointestinal upset is not a likely cause of the signs reported by the patient. Gastrointestinal upset can cause some symptoms, such as nausea, vomiting, or abdominal pain, but it does not cause headache, visual changes, or epigastric pain. Gastrointestinal upset is also not a common complication of pregnancy-induced hypertension, which is a condition that affects the blood vessels and organs, not the digestive system.
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