The most appropriate action by the nurse when the periodic acceleration in fetal heart rate is observed?

RUHS, Jaipur, M.Sc Nursing Entrance Exam-2016

Obstetrics & Gynaecology

Medium

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2016

Explanation

Periodic accelerations are temporary increases in the Fetal Heart Rate (FHR), which are a reassuring sign of a well-oxygenated fetus with an intact nervous system.
The presence of accelerations is the basis for a 'reactive' Nonstress Test (NST), which confirms fetal well-being.
For a normal and reassuring finding, the most complete nursing action is to document it in the patient's record and communicate the positive status to the mother, which helps alleviate anxiety.
This action combines clinical responsibility (documentation) with therapeutic communication (reassurance).

Option A: Notifying the doctor is not necessary because accelerations are a normal and reassuring finding, not an indication of a problem.
Option B: This option is incomplete. While monitoring should always continue, it is a passive action. A complete nursing response also includes documentation of the findings and communication with the patient.
Option C: Repositioning the mother is an intervention aimed at correcting non-reassuring FHR patterns, such as late decelerations (to improve uteroplacental perfusion) or variable decelerations (to relieve cord compression). It is not indicated for normal accelerations.

Clinical Relevance

Nursing practice connection: Knowing Interpretation of fetal heart rate (FHR) patterns and corresponding nursing interventions helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Correctly identifying reassuring FHR patterns like accelerations is crucial for preventing unnecessary medical interventions and reducing maternal anxiety.
Providing reassurance to the mother about her baby's well-being is a key therapeutic nursing intervention that can positively impact the labor experience and maternal coping.
What if? If late decelerations were observed instead of accelerations, the nurse's priority would shift to immediate intrauterine resuscitation measures: repositioning the mother to her left side, administering oxygen via a non-rebreather mask, increasing IV fluids, discontinuing any oxytocin infusion, and notifying the healthcare provider urgently.

How to Approach the Question

First, identify the clinical finding presented in the question: 'periodic acceleration in fetal heart rate.'
Recall the significance of different FHR patterns. Remember that accelerations are a reassuring sign of fetal well-being.
Evaluate the options based on this understanding. Eliminate options that describe interventions for non-reassuring patterns (e.g., repositioning the mother, notifying the doctor).
Compare the remaining options. 'Continue monitoring' is correct but passive. 'Document findings and inform mother' is a more comprehensive and proactive nursing action.
Select the option that represents the most complete professional nursing action for a reassuring finding, which includes documentation and patient communication.

Concept Tested & Keywords

Concept Tested: Interpretation of fetal heart rate (FHR) patterns and corresponding nursing interventions.
Stem keywords: periodic acceleration, fetal heart rate, nurse, action
Lead-in keywords: most appropriate
Negative lead-in flag: false