A nurse is caring for a primigravida client at 41 weeks gestation who has been in active labor for 14 hours with minimal cervical dilation progress. The fetal heart rate shows late decelerations, and the client is experiencing strong, frequent contractions. What is the priority nursing intervention?
1Administer oxygen via face mask at 8-10 L/min
2Position the client in left lateral position
3Prepare the client for immediate cesarean delivery✓ 정답
4Increase the oxytocin infusion rate
해설
Late decelerations with prolonged labor indicate fetal hypoxia and uteroplacental insufficiency, requiring immediate cesarean delivery for fetal safety. Other interventions (oxygen, positioning, oxytocin) are inadequate in this emergency context.
Clinical Judgment
This question assesses priority setting in an obstetric emergency where dystocia and fetal distress occur simultaneously. The core is the combination of two Critical Cues: 1) minimal cervical dilation progress despite 12 hours of active labor, and 2) late decelerations on the fetal heart rate tracing. Late decelerations are a clear sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. The greatest danger in this situation is progressive fetal hypoxia and acidosis. Therefore, the nurse's top priority goal is to immediately move the fetus to a safe environment, which is delivery. Conservative measures (oxygen, position changes) are only temporary palliatives and do not resolve the fundamental problems (failed labor progress + fetal hypoxia).
Memory Tip
For these complex emergencies, remember the priority as Delivery over Delay. When the two signals of "labor has stopped progressing" and "the fetus is in danger" appear together, preparing for an immediate cesarean delivery is the correct answer.
KR vs US
In Korea, there may be a tendency to attempt fetal monitoring and conservative measures for a longer period, but by NGN/US standards, when late decelerations persist and there is no labor progress, immediate notification of the physician and preparation for a cesarean section is the standard protocol. The scope of independent nursing judgment is broad, and the approach to fetal safety is very proactive.
Clinical Practice Guide
* Late Decelerations assessment: A pattern that begins after the peak of the contraction and returns to baseline late, even after the contraction ends. It is a sign of insufficient uteroplacental perfusion.
* Dystocia management: If cervical dilation in a first-time mother during the active phase is less than 1.2 cm/hour, suspect failure to progress.
* Emergency cesarean section preparation: The nurse must promptly initiate measures such as verifying surgical consent, maintaining the IV line, gastrointestinal preparation (confirming NPO status), and notifying the operating room while simultaneously reporting to the physician.
Caution
* In SATA (Select All That Apply) questions, "oxygen administration" and "left lateral position" are often included in the list of correct answers. However, remember that when a question asks for the single priority intervention, as in this case, these conservative measures cannot substitute for emergency delivery.
* Increasing Oxytocin is absolutely contraindicated. In a situation with late decelerations during already strong and frequent contractions, further strengthening uterine contractions will only worsen fetal hypoxia.
Dystocia — Difficult or delayed labor. A condition where labor progression is abnormally slow or halted due to issues with uterine contractions, the fetus, the mother's pelvis, or psychological factors (the 4 Ps).
Late Decelerations — Late deceleration. A fetal heart rate pattern that begins after the peak of a uterine contraction and returns to baseline late after the contraction ends. A sign of uteroplacental insufficiency and fetal hypoxia.
Uteroplacental Insufficiency — Uteroplacental insufficiency. A state of inadequate maternal-fetal exchange of oxygen and nutrients across the placenta. A major cause of late decelerations.
Cesarean Delivery — Cesarean section. A surgical procedure to deliver a fetus through incisions in the abdomen and uterus. An emergency delivery method performed when there is a risk to the fetus or mother.
Failure to Progress — Failure to progress in labor. A condition in the active phase of labor where cervical dilation or fetal descent is not progressing as expected. Diagnostic criteria for dystocia.