Health Promotion and Maintenance
8. A client who is a primigravida is admitted in early labor at 38 weeks' gestation. Her physician orders auscultation of fetal heart tones every 30 minutes. The RN knows that the most appropriate time to listen to fetal heart tones is:
. For 30 seconds after a contraction.
. During a contraction and for 30 seconds after the contraction.
. Between the contractions.
. During the contractions.
Test-Taking Tip
The reason for obtaining fetal heart tones is to ensure that the fetus is not having any fetal distress. Eliminate the answers that do not provide complete assessment for fetal distress.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; 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 auscultation should be performed to hear decelerations of the fetal heart rate. Correct procedure includes listening for decelerations during a contraction and for 30 seconds after the contraction, to make sure that there are no audible decelerations. Answer 2 is correct because this is the correct procedure for fetal heart tone auscultation. Answer 3 is incorrect because this answer doesn't include listening during the contraction for decelerations; therefore, it is incomplete. Answer 4 is incorrect because this answer doesn't include listening after the contraction. Late decelerations may not be heard.