More questions

More questions ( 14 Questions)

A nurse is caring for a client in labor who has an internal fetal scalp electrode applied for continuous fetal heart rate (FHR) monitoring.

The nurse notes a pattern of late decelerations on the FHR tracing.

What is the priority nursing intervention?



Correct Answer: D

Notify the health care provider. Late decelerations are a sign of uteroplacental insufficiency, which means that the blood flow and oxygen supply to the placenta and the fetus are compromised. This is a serious condition that can lead to fetal hypoxia and acidosis. The priority nursing intervention is to inform the health care provider who can assess the situation and decide on the appropriate course of action, such as delivery by cesarean section.

Choice A is wrong because changing the client’s position may not improve the blood flow to the placenta if there is a problem with the placenta itself, such as placental abruption.

Choice B is wrong because administering oxygen via face mask may not be enough to correct the fetal hypoxia caused by uteroplacental insufficiency.

Choice C is wrong because increasing intravenous fluid rate may not improve the blood flow to the placenta if there is a problem with the maternal blood pressure, such as hypotension from epidural analgesia.




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