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The nurse is performing an assessment on a client who is at 38 wks. and notes that the FHR is 174 bpm. the appropriate nursing action is to do this.
What is
Notify the physician.
Rational:
The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/min in the first trimester but slows with fetal growth to 120 to 160 beats/min near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 beats/min with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the physician. Although the nurse documents the findings, based on the information in the question, the physician needs to be notified.