QUESTION: "The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. Which of the following would the nurse do next?"
CHOICES
( X ) a.) Inform the client about the cause of the fetal heart rate pattern.
( X ) b.) Prepare the client for an immediate cesarean section.
( X ) c.) Evaluate the contraction pattern for 15 minutes.
( O ) d.) Administer oxygen at 8 to 10 liters by mask.
RATIONALE: Late decelerations signal poor placental perfusion. Therefore, oxygen should be administered at 8 to 10 liters by mask to improve fetal hypoxia. The nurse should also stop the oxytocin infusion, turn the client onto her side, and report the pattern to the attending clinician. Informing the client about fetal well-being occurs throughout the labor process, not just if problems arise. If the late deceleration pattern persists or if decreased variability occurs, then cesarean delivery may be indicated. Although the contraction pattern should be monitored throughout the induction of labor, the priority here is to provide oxygen to the compromised fetus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
