Maternal & Newborn Nursing
A nurse who is caring for a woman in labor, prepares to auscultate fetal heart rate by using Doppler…
A nurse who is caring for a woman in labor, prepares to auscultate fetal heart rate by using Doppler ultrasound device. How does the nurse determine that the fatel heart sounds are correctly?
Explanation
Core Concept: When auscultating the fetal heart rate (FHR), it is essential to distinguish the fetal heart rate from the maternal heart rate. The fetal heart rate is typically faster (110-160 bpm) than the maternal rate.
Clinical Presentation:
- Regular fetal heart tones heard via Doppler
- Maternal pulse palpable at the radial artery
Diagnosis:
- *First-line:* Doppler ultrasound or fetoscope to auscultate FHR.
- *Gold Standard:* Continuous Electronic Fetal Monitoring (EFM) for accurate FHR assessment.
Management:
- *Acute:* To confirm the nurse is hearing the FHR and not the maternal pulse, simultaneously palpate the maternal radial pulse while listening to the Doppler. If the rates differ, the Doppler is picking up the fetal heart.
- *Definitive:* Document FHR within normal range (110-160 bpm) and continue routine monitoring.