QUESTION: "External monitoring of contractions and fetal heart rate of a multigravida in labor reveal a variable deceleration pattern on the fetal heart rate. Which of the following should the nurse do first?"
CHOICES
( X ) a.) Notify the anesthesiologist.
( O ) b.) Change the client's position.
( X ) c.) Administer oxygen at 2 liters by mask.
( X ) d.) Prepare the client for a cesarean delivery.
RATIONALE: Variable decelerations, common after membranes rupture, usually indicate cord compression. Repositioning the client often helps to correct this fetal heart rate pattern. If repositioning is not successful, the clinician may choose to perform amnioinfusion-infusion of sterile saline solution into the uterus through a sterile catheter to help take the pressure off the cord. The nurse may wish to alert the obstetrician or nurse midwife, but the anesthesiologist is responsible for anesthesia, not for the fetus. Administering oxygen at 2 liters is not helpful because pressure on the cord must be relieved. Changing the client's position and administering oxygen often resolve the cord compression. There is no need to prepare the client for a cesarean delivery at this time. A cesarean delivery would be indicated for prolonged fetal distress. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
