A nurse is caring for a primigravida client at 40 weeks gestation who has been in active labor for 12 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
2Prepare the client for immediate cesarean delivery✓ 정답
3Encourage position changes and ambulation
4Increase the oxytocin infusion rate
해설
Late decelerations indicate fetal hypoxia requiring immediate delivery. Other options are supportive but insufficient for this emergency.
Core Nursing Explanation
This question integrates fetal assessment with nursing prioritization in an obstetric emergency. The scenario presents a dystocia (difficult labor) picture with two critical, interrelated findings: Key Point!Late decelerations in the fetal heart rate (FHR) and uterine hyperstimulation (strong, frequent contractions). The pathophysiological link is that hyperstimulation reduces uterine blood flow during contractions, leading to fetal hypoxia, which manifests as late decelerations. This is a non-reassuring fetal status that is not resolving with time (12 hours of labor with minimal progress).
Answer Rationale
The priority intervention is Prepare the client for immediate cesarean delivery. This is an emergency requiring definitive treatment to relieve fetal hypoxia. The combination of Watch out for confusion!non-reassuring fetal status (late decelerations) and failure to progress (arrested active phase) meets criteria for a Category III FHR tracing and obstructed labor, where expedited delivery is the standard of care. The nurse's role is to recognize the emergency, notify the provider, and prepare the client for the necessary intervention.
Distractor Analysis
Option 1 (Administer oxygen): This is a correct supportive measure for fetal hypoxia and should be done, but it is not the priority intervention. Oxygen administration treats a symptom but does not resolve the underlying cause—the hyperstimulation and obstructed labor. The nurse can initiate oxygen while preparing for delivery.
Option 3 (Encourage position changes): While position changes (e.g., left lateral) can improve placental perfusion, they are first-line interventions for early or variable decelerations. In this case, with late decelerations and hyperstimulation, the situation is too acute for conservative measures to be the priority. Ambulation is contraindicated with non-reassuring FHR patterns.
Option 4 (Increase oxytocin): This is absolutely contraindicated. Oxytocin (Pitocin) is the likely cause of the hyperstimulation. Increasing it would worsen uterine tachysystole, further compromising fetal oxygenation and potentially leading to uterine rupture.
Related Concepts
This scenario tests the nurse's ability to synthesize data: FHR patterns + labor progress + contraction pattern. It moves beyond identifying a deceleration type to understanding its clinical urgency within the context of the entire labor picture.
Concept Summary
Concept
Description
Clinical Implication
Late Decelerations
Gradual FHR decrease that starts at the peak of a contraction and recovers after the contraction ends. They are uniform in shape and mirror the contraction.
Indicates uteroplacental insufficiency and fetal hypoxia. A persistent pattern is non-reassuring.
Uterine Hyperstimulation/Tachysystole
More than 5 contractions in 10 minutes, averaged over 30 minutes, or contractions lasting >90 seconds with inadequate rest period.
Reduces intervillous blood flow, leading to fetal hypoxia. Requires intervention (stop oxytocin, consider tocolytics).
Arrest of Dilation
No cervical change for 2 hours or more in the active phase (≥6 cm dilation) with adequate contractions.
Suggests cephalopelvic disproportion (CPD) or other obstruction. Often requires cesarean delivery.
Category III FHR Tracing
Includes either absent variability with recurrent late/variable decelerations or bradycardia; or a sinusoidal pattern.
Predictive of abnormal fetal acid-base status. Requires immediate intervention to expeditiously deliver the fetus.
Side-by-Side Comparison!
FHR Deceleration Type
Shape & Timing
Pathophysiology
Nursing Action (Initial)
Early Deceleration
Mirrors contraction. Nadir at peak of contraction.
Head compression (vagal response). Benign.
Continue monitoring. No action needed.
Variable Deceleration
Variable shape, abrupt onset/offset. Often V- or U-shaped.
Umbilical cord compression.
Change maternal position (left/right, Trendelenburg). May administer IV fluid bolus.
Late Deceleration
Uniform shape, gradual. Onset after contraction starts, nadir after peak, recovers after contraction ends.
1. Position (left lateral). 2. Stop oxytocin. 3. Administer O2. 4. Notify provider. 5. Prepare for delivery if unresolved.
Anatomy, Physiology & Pharmacology Points
Physiology: Uterine contractions temporarily reduce blood flow through the spiral arteries. Adequate relaxation between contractions allows for reperfusion and oxygen delivery to the fetus. Hyperstimulation shortens this critical rest period.
Pharmacology - Oxytocin: A synthetic hormone that stimulates uterine contractions. It must be administered via an IV infusion pump with continuous monitoring. The nurse must assess for tachysystole and fetal response. The protocol for non-reassuring FHR often includes discontinuing the oxytocin infusion.
LATE for PLACENTA:Late decelerations = Placental problem.
Emergency Action for Late Decels: Think "L.O.V.E.S." Lateral position, Oxygen, stop the Volume (oxytocin), Elevate legs? (for hypotension), Support (notify provider/prepare for delivery). The "S" is the critical priority when the pattern is recurrent.
Hyperstimulation Rule: "5 in 10" is too many. More than 5 contractions in 10 minutes is tachysystole.
High-Frequency NCLEX Topics
This is a classic NCLEX-RN priority question. You will be tested on:
Prioritizing nursing actions in obstetric emergencies.
Knowing the indications and contraindications for oxytocin administration.
Understanding the criteria for failure to progress and when it constitutes an emergency.
Watch Out for Question Variations!
Variation 1 (Less Acute): "A client on oxytocin has late decelerations with every other contraction. Contractions are every 3 minutes, lasting 60 seconds. What should the nurse do first?" Answer: Stop the oxytocin infusion and reposition the client. (Delivery is not the first step here).
Variation 2 (Different Deceleration): Replace "late decelerations" with "recurrent variable decelerations." The priority action may then be to change the mother's position and administer a fluid bolus.
Variation 3 (Post-Intervention): "After stopping oxytocin and administering oxygen, the late decelerations persist. What is the nurse's next action?" Answer: Notify the provider and prepare for possible operative delivery.
Nursing Clinical Practice GuideClinical Scenario: You are the labor nurse for Maria, a 25-year-old G1P0 at 40 weeks. She has been receiving oxytocin for augmentation of labor. Over the past hour, you note her contractions are now every 1.5 minutes, lasting 90 seconds, and she rates the pain as 10/10. The external monitor shows a FHR baseline of 140 with minimal variability. With each contraction, the FHR gradually drops to 110, taking 20 seconds after the contraction ends to return to baseline. The cervical check reveals she is still only 5 cm dilated, unchanged for 3 hours.
Nursing Intervention Strategy:
Immediate Assessment & Simultaneous Action: Recognize this as a Category III FHR tracing (recurrent late decels with minimal variability) with hyperstimulation and arrest of dilation. Your brain should immediately go to "This baby needs to come out now."
First 60 Seconds:
Call for help. Verbally alert your charge nurse and shout for another nurse to stat page the obstetrician and anesthesiologist.
Stop the oxytocin infusion at the pump.
Turn the client to a left lateral position.
Apply a non-rebreather face mask at 10-15 L/min.
Increase the rate of the main IV line (lactated Ringer's) to open.
Preparation for Delivery: While doing the above, you are mentally and physically preparing for surgery.
Explain to Maria and her partner in calm, clear terms: "The baby is showing signs of stress and isn't tolerating the contractions well. We need to prepare for a cesarean delivery to keep you both safe."
Ensure the informed consent for cesarean is signed. If not, notify the provider immediately.
Start preoperative preparations: insert an indwelling urinary catheter (Foley), remove jewelry, ensure IV access is patent with a large-bore (18-gauge or larger) catheter, administer ordered preoperative antibiotics, and complete the surgical safety checklist.
Patient Safety and Precautions
Never leave the client alone during this emergency.
Communication is key: Use SBAR (Situation, Background, Assessment, Recommendation) when notifying the provider: "Situation: I have a Category III tracing with recurrent late decels and hyperstimulation. Background: G1P0, 12 hours in labor, on oxytocin. Assessment: Contractions every 1.5 min for 90 sec, cervix 5cm/100%/0 station with no change for 3 hours. FHR shows recurrent late decels to 110 with minimal variability. Recommendation: I have stopped the oxytocin, given O2, and turned her. I believe she needs immediate cesarean delivery. I have started preoperative prep."
Documentation: Document everything meticulously: time of deceleration recognition, actions taken (O2, position change, oxytocin d/c), notification of provider, provider's response, and preparation for surgery.
Start at a low dose (e.g., 1-2 mU/min) via an IV infusion pump. Increase per protocol (e.g., every 30-40 min).
To achieve adequate labor progress while minimizing risk of hyperstimulation.
2. Monitoring
Continuously monitor FHR and uterine activity. Assess for tachysystole (5+ contractions/10 min).
Early detection of non-reassuring patterns allows for timely intervention.
3. For Hyperstimulation
STOP THE OXYTOCIN. Do not just decrease it. Turn it off.
Immediate removal of the stimulant is required to restore uterine blood flow.
4. For Late Decelerations
Follow the "L.O.V.E.S." mnemonic. If pattern persists despite corrective measures, prepare for delivery.
Persistent late decels indicate ongoing fetal hypoxia requiring definitive treatment.
A Word from Your Senior Nurse
"In labor and delivery, you are the guardian for two patients. Your vigilant assessment of that FHR strip is what stands between a routine birth and a neonatal resuscitation. Never ignore a persistent late deceleration pattern, especially with poor variability. It's the baby's only way of saying, 'I'm not getting enough oxygen.' When you see that pattern combined with a lack of progress, your nursing judgment must shift from 'supportive care' to 'emergency preparedness.' Trust your training. The ability to stay calm, act decisively, and communicate effectively in these moments is what defines an expert labor nurse. For the NCLEX, they are testing if you can make that critical shift in thinking. Always ask yourself: 'Is this pattern benign, suspicious, or ominous? And what is the most definitive action to correct it?'"
Late Deceleration — A periodic deceleration of the fetal heart rate (FHR) that is gradual in onset and return, with the nadir (lowest point) occurring after the peak of the uterine contraction. It is caused by uteroplacental insufficiency and indicates fetal hypoxia.
Uterine Hyperstimulation — Excessive uterine activity, defined as more than five contractions in 10 minutes (averaged over 30 minutes), contractions lasting longer than 90 seconds, or inadequate uterine relaxation between contractions. It can compromise fetal oxygenation.
Arrest of Dilation — A diagnosis of abnormal labor progress where no cervical change occurs for 2 hours or more during the active phase of labor (cervix ≥6 cm dilated) despite adequate uterine contractions.
Category III FHR Tracing — A classification of fetal heart rate patterns that are abnormal and predictive of abnormal fetal acid-base status. Includes absent variability with recurrent late or variable decelerations, or bradycardia. Requires prompt evaluation and intervention.
Oxytocin — A synthetic hormone used to induce or augment labor by stimulating uterine contractions. It is administered via controlled IV infusion and requires continuous maternal and fetal monitoring due to risks of hyperstimulation and fetal distress.