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: Cheese is a good source of calcium, protein, and vitamin B12, but not folates. Folate is a water-soluble vitamin that is essential for the synthesis of DNA and the prevention of neural tube defects in the fetus.
Choice B reason: Potatoes are a good source of carbohydrates, potassium, and vitamin C, but not folates. Folate is found mainly in plant-based foods, especially dark green vegetables.
Choice C reason: Chicken is a good source of protein, iron, and zinc, but not folates. Folate is more abundant in legumes, nuts, and seeds than in animal products.
Choice D reason: Green leafy vegetables are a good source of folates, as well as vitamin A, vitamin K, and fiber. Folate is also known as folic acid when it is added to fortified foods or supplements. Pregnant women need at least 600 micrograms of folate per day.
Correct Answer is A
Explanation
Choice A reason: Intense abdominal pain is the most prevalent clinical manifestation of abruptio placentae, as it indicates the detachment of the placenta from the uterine wall and the bleeding into the uterine muscle. The pain can be localized or diffuse, and it can be constant or intermittent. The pain can also radiate to the back or the shoulder.
Choice B reason: Cramping is not the most prevalent clinical manifestation of abruptio placentae, as it is not specific to the condition. Cramping can occur in normal pregnancy or in other complications such as preterm labor, infection, or cervical insufficiency.
Choice C reason: Uterine activity is not the most prevalent clinical manifestation of abruptio placentae, as it is not specific to the condition. Uterine activity can occur in normal pregnancy or in other complications such as preterm labor, infection, or placenta previa.
Choice D reason: Bleeding is not the most prevalent clinical manifestation of abruptio placentae, as it may or may not be present. Bleeding can be concealed or revealed, depending on the location and extent of the placental separation. Concealed bleeding occurs when the blood is trapped behind the placenta and does not exit the vagina. Revealed bleeding occurs when the blood passes through the cervix and exits the vagina.
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