The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply)

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.

Choice A reason: Variability refers to the fluctuations in the FHR that are irregular in amplitude and frequency. It reflects the balance between the sympathetic and parasympathetic nervous systems of the fetus. A normal variability is between 6 and 10 beats/min, which indicates a healthy and well-oxygenated fetus.

Choice B reason: Late decelerations are decreases in the FHR that begin after the peak of a contraction and return to the baseline after the contraction ends. They are caused by uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. Mild late decelerations are not reassuring and may indicate fetal hypoxia or acidosis².

Choice C reason: FHR should change as a result of fetal activity, such as movement, sleep, or stimulation. A change in the FHR indicates a responsive and well-oxygenated fetus. A lack of change in the FHR may indicate fetal distress or compromise.

Choice D reason: The average baseline rate is the mean FHR rounded to increments of 5 beats/min during a 10-minute window, excluding periods of marked variability, accelerations, or decelerations. A normal baseline rate is between 110 and 160 beats/min. A baseline rate between 100 and 140 beats/min is not necessarily abnormal, but it may indicate fetal bradycardia (slow heart rate) or tachycardia (fast heart rate), depending on the gestational age and other factors.