During a first-trimester fetal heart rate assessment, a fetal heart rate of 160 beats per minute is observed. What action should the nurse take?

During a first-trimester fetal heart rate assessment, a fetal heart rate of 160 beats per minute is observed. What action should the nurse take?

• A. Document the findings
• B. Notify the health care provider of the finding
• C. Wait 15 minutes and recheck the FHR
• D. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time

Answer: (A)

Normal fetal heart rate in the first trimester is roughly 110–160 beats per minute. A reading of 160 bpm sits at the upper end of normal and, as a single measurement, does not require urgent action. The appropriate approach is to document the finding in the chart and continue routine monitoring. Only if subsequent assessments show a persistently elevated rate or other signs of fetal distress would contacting the health care provider be warranted; otherwise, there’s no need for additional intervention at this moment.

Normal fetal heart rate in the first trimester is roughly 110–160 beats per minute. A reading of 160 bpm sits at the upper end of normal and, as a single measurement, does not require urgent action. The appropriate approach is to document the finding in the chart and continue routine monitoring. Only if subsequent assessments show a persistently elevated rate or other signs of fetal distress would contacting the health care provider be warranted; otherwise, there’s no need for additional intervention at this moment.