Question

A client is in active labor with external monitoring in use. The nurse notes abrupt and rapid fluctuations in the fetal heart rate (FHR) from baseline to 90 beats per minute and back to baseline on the monitoring device. The fluctuations in fetal heart rate occur with no relationship to the contraction pattern. The client watched the monitor and asks, " Is something wrong with the baby?" Which response by the nurse is BEST?

A. "This FHR pattern is still within normal range."

B. "An emergency cesarean section is indicated."

C. "There is interference with the fetal monitor."

D. "This is a potential problem that requires a position change."

Answer 1

The best nurse's response would be that it's a potential problem requiring a position change, acknowledging the possibility of fetal distress due to the abrupt fluctuations in fetal heart rate not corresponding with contractions. It is vital to assess further and ensure the well-being of both mother and child.Thus the correct option is D.

Step-by-step explanation:

If a client in active labor is experiencing abrupt and rapid fluctuations in the fetal heart rate (FHR) with values dropping to 90 beats per minute and then returning back to baseline, and these fluctuations do not correlate with the contraction pattern, the nurse should acknowledge that these observations may indicate a potential issue. The appropriate response for the nurse would be D, "This is a potential problem that requires a position change." Although these fluctuations might occasionally be due to monitor interference, the fact that there are abrupt changes to 90 bpm is concerning and warrants action. The nurse should assess the situation further, reposition the mother, and possibly perform additional monitoring or interventions as indicated.

It is important for healthcare providers to monitor changes in heart rate and to differentiate between transient and more concerning patterns of fetal distress. Given that each contraction reduces oxygenated blood flow to the fetus temporarily, adequate relaxation between contractions is vital for fetal wellbeing. Sustained alterations in FHR can indicate significant distress and may lead to interventions such as an emergency cesarean section, but this decision is based on a comprehensive assessment of the situation, not just isolated FHR monitor readings.