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 B
Explanation
Choice A reason: Intranasal spray is not a correct option, as urofollitropin is not available in this form. Intranasal spray is a method of delivering some medications through the nose, where they can be absorbed by the mucous membranes. However, urofollitropin is a protein hormone that would be degraded by the enzymes in the nasal cavity and would not reach the bloodstream effectively.
Choice B reason: Intramuscular injection is the correct option, as urofollitropin is available in this form. Intramuscular injection is a method of delivering medications into the muscle tissue, where they can be absorbed by the blood vessels. Urofollitropin is a protein hormone that needs to be injected into the body to bypass the digestive system and avoid being broken down by the stomach acids and enzymes. Urofollitropin is usually injected into the thigh or buttock muscles once a day for several days, depending on the dosage and the response².
Choice C reason: Vaginal suppository is not a correct option, as urofollitropin is not available in this form. Vaginal suppository is a method of delivering medications into the vagina, where they can be absorbed by the vaginal walls or act locally. Urofollitropin is a protein hormone that would not be absorbed well by the vaginal mucosa and would not reach the ovaries, where it is supposed to stimulate the development of the follicles (eggs).
Choice D reason: Tablet is not a correct option, as urofollitropin is not available in this form. Tablet is a method of delivering medications orally, where they can be swallowed and absorbed by the gastrointestinal tract. Urofollitropin is a protein hormone that would be destroyed by the stomach acids and enzymes and would not reach the bloodstream or the ovaries.
Correct Answer is B
Explanation
Choice A reason: A total placenta previa is when the placenta completely covers the internal os, blocking the baby's exit from the uterus.
Choice B reason: Placenta previa is a condition where the placenta implants in the lower uterine segment and may cover or be near the cervical internal os. When the placental edge just reaches the internal os but does not cover it, it is called a marginal previa.
Choice C reason: A complete placenta previa is when the placenta partially covers the internal os, reducing the space for the baby to pass through.
Choice D reason: "Partial placenta previa" refers to a situation where the placenta partially covers the internal cervical os — meaning some, but not all, of the opening is obstructed by placental tissue.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.