The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal…

Question

Options

• ANotify physician of nonreassuring FHR pattern.
• BTurn the client to her left side.
• CStart IV for fetal distress and administer O2 at 6-8 liters by mask.
• DEvaluate to see if the monitor strip is reassuring.

• A
  6% (2)
• B
  9% (3)
• C
  3% (1)
• D
  82% (28)

Explanation

(A) These indices are within normal parameters; therefore, the nurse does not need to contact the (B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.

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