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Difficulty: EasyAnte/Intra/Postpartum and Newborn Care

A nurse is evaluating the electronic fetal monitor tracing for a client in active labor. The nurse notes recurrent, abrupt decreases in the fetal heart rate that drop below the baseline and have no consistent relationship with the onset of uterine contractions. Which of the following actions should the nurse perform? Select all that apply.

  1. Assist the client into a lateral or knee-chest positionAnswer
  2. Administer supplemental oxygen via a non-rebreather maskAnswer
  3. Stop the continuous intravenous oxytocin infusion if it is runningAnswer
  4. D
    Document the pattern as early decelerations and continue routine monitoring
  5. E
    Position the client flat in a supine posture to prepare for provider examination
  6. F
    Delegate adjusting the intravenous fluid rate to the unlicensed assistive personnel (UAP)

Answer

The correct actions are to assist the client into a lateral or knee-chest position, administer supplemental oxygen, and stop the oxytocin infusion.
The monitor tracing describes variable decelerations, which indicate umbilical cord compression. The correct nursing interventions are aimed at relieving pressure on the cord and improving fetal oxygenation. These necessary actions include repositioning the client (such as a lateral or knee-chest position), administering supplemental oxygen, and discontinuing uterine stimulants like oxytocin to reduce uterine workload.

Step-by-Step Solution

1
Identify the fetal heart rate pattern described in the scenario.
The abrupt decreases that are unrelated to contractions indicate variable decelerations.
Accurate interpretation of the fetal monitor tracing is required to determine the underlying cause, which in this case is umbilical cord compression.
2
Determine the appropriate interventions for umbilical cord compression.
Interventions must focus on relieving pressure on the cord and optimizing fetal oxygenation.
Variable decelerations are a sign of fetal stress requiring immediate intrauterine resuscitation measures.
3
Select the nursing actions that match the goals of intrauterine resuscitation.
Repositioning the client, applying oxygen, and stopping oxytocin are the appropriate actions.
These specific actions directly address the physiological cause of the decelerations and support fetal recovery.

Key Concept

Variable Decelerations and Intrauterine Resuscitation
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Topics

Ante/Intra/Postpartum and Newborn Care

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