Question

A nurse assesses the fetal heart rate at 188 beats/minute in a woman who is receiving a tocolytic medication to halt contractions. Which action should the nurse take first?

A. Assess the maternal temperature and call the primary care provider.
B. Document the findings in the patients chart.
C. Have the woman get up and walk or change position.
D. Perform a vaginal exam to assess for cord compression.

Answer 1

The nurse should first assess the maternal temperature and then alert the primary care provider, as a high fetal heart rate could indicate fetal distress or maternal infection.

Step-by-step explanation:

The fetal heart rate at 188 beats/minute in a woman receiving tocolytic medication to halt contractions may indicate fetal distress. The nurse's first action should be to assess the maternal temperature since a high maternal temperature can provoke tachycardia in the fetus, which could be a sign of infection such as chorioamnionitis. Following this assessment, the nurse should contact the primary care provider for further orders, as this situation could escalate into an emergency requiring expedited delivery.