FETAL HEART RATE ASSESSMENT VIA
INTERMITTENT AUSCULTATION AND
ELECTRONIC MONITO EXAM AND ACTUAL
CORRECT ANSWERS.
During assessment of the FHR using IA on a patient at 40 weeks' gestation,
the nurse hears a decrease to 90 beats per minute with a contraction. The
nurse listens through another contraction and again hears a decrease to 90
beats per minute from the baseline of 130 beats per minute. What is the
nurse's next action? - CorreCt Answers -C. Apply continuous fetal monitor
ultrasound and a tocotransducer.
Rationale: The nurse's next action should be to apply a continuous fetal
monitor ultrasound and a tocotransducer to determine the type of
decelerations and the variability of the FHR. With an indeterminate FHR,
continuing to use IA would not be appropriate. Although the nurse may
need to check the patient's cervix, doing so is not the next action. Placing an
internal fetal electrode is not necessary unless the nurse cannot trace the
FHR externally.
The nurse who is caring for a term patient in labor is assessing the FHR
using IA. The nurse should know that a Category III fetal heart rate tracing
cannot be identified using IA for which reason? - CorreCt Answers -D. IA
cannot be used to assess variability.
Rationale: IA cannot be used to assess baseline variability, which must be
absent in a Category III tracing in addition to recurrent late or variable
decelerations, bradycardia, or a sinusoidal pattern. IA can be used to assess
fetal rhythm as regular or irregular. IA can be used to assess decreases or
decelerations in the FHR; however, the type of decelerations needs to be
, determined by external fetal monitoring. IA can be used to assess the
baseline FHR.
A student nurse is caring for a patient who is a multipara in early labor.
After an initial 30-minute assessment of the FHR with an external fetal
monitor, the practitioner orders IA. The student nurse asks the patient's
nurse to explain the benefits of IA. How should the nurse respond? -
CorreCt Answers -B. IA is noninvasive and allows the patient increased
mobility.
Rationale: IA is beneficial because it is a hands-on, noninvasive technique
that allows patients to have increased mobility and provides an opportunity
for additional contact with the patient. IA does not require less nursing
care: it requires a 1:1 nurse-to-patient ratio. IA does not allow continuous
assessment of the FHR because it is intermittent. IA can determine
decreases or decelerations in the FHR but not the type of FHR decreases or
decelerations.A patient in early labor is being admitted to the labor and
delivery unit and asks the nurse if being on the electronic fetal monitor
throughout the labor will be necessary. What should the nurse consider
before answering the patient? - CorreCt Answers -B. Practitioner's orders,
organization's practice, health care team member availability, and patient
preferences
Rationale: The nurse should review the practitioner's orders and know the
organization's practice before caring for the patient. The nurse should also
be aware of the availability of required health care team members if IA will
be used. Although patients have the right to decline continuous electronic
fetal monitoring, the patient should be informed if the clinical findings
warrant continuous monitoring. When possible, patient care should be
based on patient preferences rather than on health care team preferences.
Although cost containment should always be considered when caring for
INTERMITTENT AUSCULTATION AND
ELECTRONIC MONITO EXAM AND ACTUAL
CORRECT ANSWERS.
During assessment of the FHR using IA on a patient at 40 weeks' gestation,
the nurse hears a decrease to 90 beats per minute with a contraction. The
nurse listens through another contraction and again hears a decrease to 90
beats per minute from the baseline of 130 beats per minute. What is the
nurse's next action? - CorreCt Answers -C. Apply continuous fetal monitor
ultrasound and a tocotransducer.
Rationale: The nurse's next action should be to apply a continuous fetal
monitor ultrasound and a tocotransducer to determine the type of
decelerations and the variability of the FHR. With an indeterminate FHR,
continuing to use IA would not be appropriate. Although the nurse may
need to check the patient's cervix, doing so is not the next action. Placing an
internal fetal electrode is not necessary unless the nurse cannot trace the
FHR externally.
The nurse who is caring for a term patient in labor is assessing the FHR
using IA. The nurse should know that a Category III fetal heart rate tracing
cannot be identified using IA for which reason? - CorreCt Answers -D. IA
cannot be used to assess variability.
Rationale: IA cannot be used to assess baseline variability, which must be
absent in a Category III tracing in addition to recurrent late or variable
decelerations, bradycardia, or a sinusoidal pattern. IA can be used to assess
fetal rhythm as regular or irregular. IA can be used to assess decreases or
decelerations in the FHR; however, the type of decelerations needs to be
, determined by external fetal monitoring. IA can be used to assess the
baseline FHR.
A student nurse is caring for a patient who is a multipara in early labor.
After an initial 30-minute assessment of the FHR with an external fetal
monitor, the practitioner orders IA. The student nurse asks the patient's
nurse to explain the benefits of IA. How should the nurse respond? -
CorreCt Answers -B. IA is noninvasive and allows the patient increased
mobility.
Rationale: IA is beneficial because it is a hands-on, noninvasive technique
that allows patients to have increased mobility and provides an opportunity
for additional contact with the patient. IA does not require less nursing
care: it requires a 1:1 nurse-to-patient ratio. IA does not allow continuous
assessment of the FHR because it is intermittent. IA can determine
decreases or decelerations in the FHR but not the type of FHR decreases or
decelerations.A patient in early labor is being admitted to the labor and
delivery unit and asks the nurse if being on the electronic fetal monitor
throughout the labor will be necessary. What should the nurse consider
before answering the patient? - CorreCt Answers -B. Practitioner's orders,
organization's practice, health care team member availability, and patient
preferences
Rationale: The nurse should review the practitioner's orders and know the
organization's practice before caring for the patient. The nurse should also
be aware of the availability of required health care team members if IA will
be used. Although patients have the right to decline continuous electronic
fetal monitoring, the patient should be informed if the clinical findings
warrant continuous monitoring. When possible, patient care should be
based on patient preferences rather than on health care team preferences.
Although cost containment should always be considered when caring for
