A nurse is monitoring a laboring client and observes the following fetal heart rate (FHR) pattern: baseline FH…

Question

A nurse is monitoring a laboring client and observes the following fetal heart rate (FHR) pattern: baseline FHR of 140 bpm with recurrent variable decelerations dropping to 70 bpm lasting 60-90 seconds, slow return to baseline, and minimal variability. What is the most appropriate immediate nursing action?

Accepted Answer

보기 1: Change the client's position to left lateral and administer oxygen via face mask at 8-10 L/min

Variable decelerations with slow return and minimal variability suggest cord compression and hypoxia; immediate position change and oxygen administration are priority interventions, while other options (continuing monitoring, immediate cesarean without assessment, or increasing IV/pushing) delay necessary care.

Answer

보기 2: Continue monitoring and document the findings as this is a normal labor pattern

Answer

보기 3: Prepare for immediate cesarean delivery and notify the anesthesiologist

Answer

보기 4: Increase the IV fluid rate and encourage the client to push with contractions

Concept	Description	Nursing Implication
Variable Decelerations	Abrupt, V-shaped FHR drops often due to umbilical cord compression.	First action: Change maternal position (left lateral, knee-chest) to relieve pressure.
Minimal Variability	Amplitude range of ≤5 bpm. Indicates fetal sleep, CNS depression, or hypoxia.	When combined with decelerations, it's a sign of non-reassuring status. Requires intervention.
Intrauterine Resuscitation	Immediate measures to improve fetal oxygenation: Position change, O2, IV fluids, discontinue oxytocin.	The nurse's first-line response to a non-reassuring FHR pattern.
Non-Reassuring FHR Pattern	Features include recurrent late/variable decels, minimal variability, tachycardia, bradycardia.	Triggers nursing interventions and notification of the provider.

FHR Deceleration Type	Shape & Timing	Likely Cause	Priority Nursing Action
Variable	Abrupt, variable shape. Onset, nadir, and recovery variable relative to contraction.	Umbilical cord compression	Change maternal position (left lateral, knee-chest).
Late	Gradual U-shape. Nadir occurs after the peak of the contraction.	Uteroplacental insufficiency	Discontinue oxytocin (if infusing), position left lateral, administer O2.
Early	Mirror image of contraction. Nadir coincides with peak of contraction.	Head compression (normal in active labor)	Typically benign. Continue monitoring, no intervention needed.

성장을 멈추지 마세요

마이메르시로 국가고시 완벽 대비