Health Promotion and Maintenance
84. A client, who is gravida 1, para 0, presents to labor and delivery with contractions every 3 minutes. The client states that she has not felt the baby move for the last 2 hours. What action should the nurse take first?
. Call the physician.
. Place the client on an external fetal monitor.
. Start an IV.
. Obtain maternal vital signs.
Test-Taking Tip
The key word is fetal. Focus on what is the most important evaluation of fetal status. Calling the physician is always required, but an assessment needs to be completed so the physician can understand the condition.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because an assessment should be completed before calling the physician. Answer 2 is correct because decreased fetal movement may be a sign of hypoxia in the fetus or a fetal demise. Placing the client on a fetal monitor will assist the nurse to evaluate the fetal well-being. Answer 3 is incorrect because starting an IV will not demonstrate fetal well-being, or do anything about evaluating the decreased fetal movement. Answer 4 is incorrect because maternal vital signs are not as crucial at this time. Evaluating the fetus is most important when a client presents with decreased fetal movement.