A nurse is evaluating the fetal monitoring strip of a laboring primigravida at 38 weeks gestation who is receiving an oxytocin infusion and has external fetal monitors and an intrauterine pressure catheter in place. Which of the following interventions should the nurse implement? Click on the exhibit button for additional information. Select all that apply.
19 July -NCLEX Daily Practice Questions
1. Administer supplemental oxygen by mask
2. Initiate an IV bolus of 0.9% saline
3. “Prepare for amnioinfusion
4. Reposition the client to supine
5. Stop the oxytocin infusion
Late decelerations occur after the onset of a uterine contraction and continue beyond its end. The lowest point (nadir) occurs near the end of the contraction before the fetal heart rate gradually returns to baseline. Late decelerations occur when fetal oxygenation is compromised (eg, uteroplacental insufficiency, uterine tachysystole, hypotension). Immediate steps to correct late decelerations include: Stopping oxytocin if it is being administered (Option 5) Repositioning the client to the left/right side Administering oxygen by face mask (Option 1) Administering an IV bolus of isotonic fluid (eg, lactated Ringer solution, 0.9% saline) as needed (Option 2) If late decelerations persist or variability is absent or minimal, the nurse should prepare for emergency delivery. (Option 3) Amnioinfusion is administered through an intrauterine pressure catheter to relieve variable decelerations, not late decelerations; variable decelerations are usually caused by cord compression secondary to loss of amniotic fluid (eg, after rupture of membranes, because of oligohydramnios). (Option 4) Supine positioning can obstruct blood flow to the placenta. The client should be placed in a side-lying position to promote placental perfusion. This action relieves compression of the aorta and inferior vena cava, which can affect cardiac output, cause hypotension, and decrease placental perfusion. Educational objective: Late decelerations occur when oxygenation to the fetus is compromised and require immediate intervention. The nurse caring for a client with late decelerations should stop oxytocin, place the client in a side-lying position, apply oxygen by face mask, and administer an IV fluid bolus as needed.
