2024 PN NCLEX Questions Nursing Practice Question
A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?
Correct Answer: B
Rationale: Documenting the findings is essential as it provides a clear record of the fetal heart rate (FHR) at this stage of pregnancy. An FHR of 160 beats/min is within the normal range for the first trimester, typically between 120-180 beats/min, making immediate notification unnecessary.
Option A is incorrect because there is no indication of abnormality that warrants alerting the healthcare provider. Option C, while reassuring, is not a priority action; proper documentation should come first. Option D is not appropriate, as the FHR is already within normal limits, and rechecking is unnecessary unless there are concerns.