A nurse is reading a Fetal monitor strip and notes accelerations. What interventions would the nurse anticipate to do next?

Nothing-this is a normal finding

Place patient on her left side

Give oxygen

Call provider

Answer and Explanation

The Correct Answer is A

A. Nothing—this is a normal finding. Fetal heart rate accelerations are reassuring and indicate good fetal oxygenation and well-being. No intervention is needed.

B. Place patient on her left side. Changing position is an intervention for decelerations or abnormal fetal heart rate patterns, not for accelerations.

C. Give oxygen: Oxygen is administered in cases of fetal distress, such as prolonged decelerations or bradycardia, but not for normal accelerations.

D. Call provider. Accelerations are a positive sign, and there is no need to call the provider for this normal finding.

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Correct Answer is D

Explanation

A. Pain just above the navel: Labor pain typically begins in the lower abdomen or back. Pain above the navel is not a definitive sign of labor.

B. Contractions every 5 to 10 min. Regular contractions are a sign of labor, but they must be accompanied by cervical changes (dilation and effacement) to confirm true labor.

C. Amniotic fluid in the vaginal vault. The presence of amniotic fluid indicates rupture of membranes, but it does not confirm labor unless cervical changes are present.

D. Cervical dilation and effacement. Cervical dilation (opening) and effacement (thinning) are definitive signs of true labor.

A. "Count the fetal heart rate for 15 seconds to determine the baseline." B. "Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor." C. "Auscultate the fetal heart rate every 30 minutes during the second stage of labor." D. "Count the fetal heart rate after a contraction to determine baseline changes."

Correct Answer is D

Explanation

A. "Count the fetal heart rate for 15 seconds to determine the baseline." The fetal heart rate (FHR) should be counted for a full minute to determine the baseline, not just for 15 seconds.

B. "Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor." The fetal heart rate is typically auscultated every 30 minutes in low-risk clients during the first stage of labor.

C. "Auscultate the fetal heart rate every 30 minutes during the second stage of labor." The fetal heart rate should be auscultated every 15 minutes during the second stage of labor, not every 30 minutes.

D. "Count the fetal heart rate after a contraction to determine baseline changes." It is important to assess the fetal heart rate after a contraction to determine if there are any decelerations or baseline changes that may indicate fetal distress.

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A nurse is reading a Fetal monitor strip and notes accelerations. What interventions would the nurse anticipate to do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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