A registered nurse is caring for a laboring client at 39 weeks of gestation. While observing the external fetal monitor, the nurse notes abrupt decreases in the fetal heart rate from a baseline of 140/min to 105/min, lasting approximately 20 seconds before rapidly returning to baseline. These decreases are V-shaped and occur inconsistently, often independent of uterine contractions. Based on these findings, what is the priority nursing intervention?
- Assist the client into a side-lying or knee-chest positionAnswer
- BDocument the pattern as an expected physiological response to fetal head compression
- CIncrease the rate of the continuous intravenous oxytocin infusion
- DInstruct unlicensed assistive personnel to obtain the client's maternal vital signs
Answer
Assist the client into a side-lying or knee-chest position
The fetal heart rate tracing describes variable decelerations, which are characterized by abrupt decreases in the heart rate that may or may not correlate with uterine contractions. Variable decelerations are caused by mechanical umbilical cord compression. The priority nursing intervention is to immediately reposition the client, such as turning them to a lateral side-lying or knee-chest position. This physical shift relieves the pressure on the umbilical cord, directly treating the underlying cause and rapidly improving fetal oxygenation.
Step-by-Step Solution
Key Concept
Management of Variable Fetal Heart Rate Decelerations