RN Nursing · Fetal Heart Rate Monitoring · Practice question
A nurse in an antepartum unit is caring for a client. Click to highlight the findings that indicate the interventions have been effective. To deselect a finding, click on the finding again.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours ago and is a greenish color." Client also reports contractions began about 4 hr ago and have become consistently strong and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad. Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min. Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0 to 10, breathing well through contractions. FHR 168/min, minimal variability. Client denies epigastric pain or visual disturbances, Trace of edema noted to bilateral lower extremities.
2130:
Contractions occurring every 3 to 3.5 min, lasting 60 to 80 seconds. Moderate amount of bloody show noted. Vaginal examination performed. Cervix dilated 6 cm, 90% effaced, +1 station. FHR 160/min with minimal variability. Recurrent variable decelerations noted with decrease in FHR to 110/min. Client tearful and anxious. Rating contraction pain as an 8 on a scale of 0 to 10, requests epidural. Anesthesiologist notified.
2230:
Contractions occurring every 2.5 to 3 min, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2000:
Temperature 36.7°C (98.1°F)
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 128/84 mm Hg
Oxygen saturation 98% on room air
2100:
Temperature 37.5°C (99.5°F)
Heart rate 104/min
Respiratory rate 20/min
Blood pressure 132/84 mm Hg
Oxygen saturation 98% on room air
2230:
Temperature 38°C (100.4°F)
Oxygen saturation 98% on room air
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
-
Nurses' Notes 2230: Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted. Vital Signs 2230: Temperature 38°C (100.4°F) Heart rate 88/min Respiratory rate 16/min Blood pressure 122/80 mm Hg Oxygen saturation 98% on room air
Answer & explanation
Correct:
The interventions implemented included oxygen administration, repositioning, IV fluid bolus, amnioinfusion, and epidural placement. The 2230 nurse's note and vital signs should be reviewed for evidence of effectiveness. The segment at index 19 — 'Contractions occurring every 2.5 to 3 min, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted' — is the most critical indicator of effectiveness: the FHR has returned to a normal range, variability has improved from minimal to moderate, accelerations are present (a reassuring sign), and decelerations have resolved. These fetal heart rate changes directly reflect successful intervention for fetal compromise. The heart rate at 2230 of 88/min (index 52) shows improvement from 104/min, indicating resolution of maternal tachycardia associated with stress or early infection response. The respiratory rate of 16/min (index 54) is normal and down from 20/min, reflecting a calmer, more physiologically stable state. The blood pressure of 122/80 mm Hg (index 56) shows improvement and is within a safer range compared to earlier readings. These vital sign improvements combined with the improved fetal monitoring findings collectively indicate that interventions were effective. The 2000 and 2100 segments represent baseline and worsening data, not evidence of effectiveness.
Practise Fetal Heart Rate Monitoring questions
Work through full question sets with instant rationales, timed exams, and progress tracking.
Start practising freeRelated practice questions
- In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/minute from a rate of 160 beats/minute earlier in the pregnancy. What is the nurse's first action?
- A nurse repositions the tocodynamometer (TOCO) several times for a client who is in active labor and whose uterine contraction tracing has not been recording accurately. Which of the following steps should the nurse take to obtain an accurate assessment?
- In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/minute from a rate of 160 beats/minute earlier in the pregnancy. What is the nurse's first action?
- A nurse places a tocodynamometer (TOCO) transducer on the client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?