Health Promotion and Maintenance
32. A client, who is gravida 1, para 0 at 40 weeks' gestation, is in the active phase of labor. The client has had no identified risk factors during her prenatal care. A nurse evaluates the fetal monitor strip at 10:00 hours. The fetal heart rate (FHR) is 130 with moderate variability, and accelerations are present, but no decelerations. At what time should the nurse reevaluate the FHR?
Test-Taking Tip
Two key concepts guide the interval of evaluating the fetal heart rate tracing: the risk factors (in this case, none) and the phase of labor (in this case, active labor).
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; 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 this client in labor is a low risk with a reassuring fetal heart rate tracing. Five minutes is too frequent for a client who is a low risk. Answer 2 is incorrect because this client in labor is a low risk with a reassuring fetal heart rate tracing. Fifteen minutes is too frequent for a low-risk client. It is an appropriate interval for a client who is high risk. Answer 3 is correct because reevaluating the fetal heart rate tracing every 30 minutes is the recommended interval for a client who is low risk. Answer 4 is incorrect because 60 minutes is too long an interval for a client in active labor.
