A nurse is caring for a laboring client at 38 weeks gestation. The fetal heart rate monitor shows late decelerations with moderate variability. The client's cervix is 6 cm dilated, and contractions are occurring every 2-3 minutes. What is the priority nursing intervention?
1Encourage the client to push with contractions to expedite delivery
2Position the client in left lateral position and administer oxygen✓ 정답
3Increase the rate of oxytocin infusion to strengthen contractions
4Prepare for immediate cesarean section delivery
해설
Late decelerations with moderate variability indicate uteroplacental insufficiency and fetal hypoxia. The priority is to improve fetal oxygenation by repositioning to left lateral and administering oxygen, which addresses the underlying cause. Other options may worsen the situation or are premature.
Clinical Judgment
The core of this problem is determining the priority of immediate nursing interventions when a concerning fetal heart rate pattern appears. Late Decelerations are a pattern that begins after the peak of a contraction and returns to baseline only after the contraction ends, and it is the most important sign suggesting Notify HCP! uteroplacental insufficiency. Moderate Variability is a positive sign that the fetus is not yet in complete distress, so there is an opportunity to reverse the situation through immediate intrauterine resuscitation. The priority is to improve fetal oxygenation as quickly as possible. The left lateral position reduces compression of the inferior vena cava, immediately increasing maternal cardiac output and placental perfusion, while oxygen administration increases maternal oxygen saturation, boosting oxygen delivery to the fetus. This is the standardized first response.
Memory Tip: When you see Late Decelerations, think "Late = Lateral & Low-Flow O2." It means that because it came late (Late), you turn the patient to the side (Lateral) and give oxygen (O2) to improve placental blood flow (Flow).
KR vs US: The basic principles for managing late decelerations (position change, oxygen administration, fluid bolus, discontinuing oxytocin) are the same in both Korea and the US. However, the US NGN exam tends to emphasize the nurse's independent judgment and immediate intervention more. An approach of "reporting to the provider while simultaneously starting immediate interventions according to standard protocols" is more appropriate than "reporting to the provider and waiting for orders."
임상 시나리오
Clinical Practice Guide
When late decelerations are observed, the nurse can respond systematically by following the mnemonic D.R. C. B.R.A.I.N.
Discontinue oxytocin
Reposition to lateral position
Call for help/Notify HCP
Boost IV fluids
Remote monitoring if applicable
Administer O2
Improve placental perfusion
Note time and document
Caution: A trap in SATA (Select All That Apply) questions is the excessive leap that "fetal distress = immediate cesarean section." The presence of moderate variability means the fetus still has compensatory mechanisms, so conservative interventions should be attempted first. Also, increasing the oxytocin infusion rate is a fatal choice that only worsens the situation.
핵심 개념
Late Decelerations — Late deceleration. A periodic decrease in fetal heart rate that begins after the peak of a uterine contraction and returns to baseline after the contraction ends. The most important pattern suggesting uteroplacental insufficiency.
Moderate Variability — Moderate variability. The amplitude fluctuation of the fetal heart rate baseline is 6-25 bpm. A positive indicator that the fetal central nervous system is functioning normally and oxygen supply is still adequate.
Intrauterine Resuscitation — Intrauterine resuscitation. A series of conservative interventions performed to optimize fetal oxygen supply when fetal distress is suspected. These include left lateral positioning, oxygen administration, intravenous fluid administration, and discontinuation of oxytocin.
Uteroplacental Insufficiency — Uteroplacental insufficiency. A condition where blood flow to the uterus or the function of the placenta itself is reduced, failing to supply sufficient oxygen and nutrients to the fetus. The main pathophysiology of late decelerations.
Active Phase of Labor — Active phase of labor. The stage where cervical dilation progresses from 6 cm to 10 cm (full dilation). Characterized by regular and strong uterine contractions, and serves as the background for problematic situations.