A nurse is monitoring a laboring client when the fetal heart rate monitor shows late decelerations with minimal variability. The client is at 38 weeks gestation, cervix is 6 cm dilated, and contractions are occurring every 2-3 minutes. What is the nurse's priority action?
1Increase the oxytocin infusion rate to strengthen contractions
2Encourage the client to push with the next contraction
3Position the client in left lateral position and administer oxygen✓ 정답
4Prepare for immediate vaginal delivery
해설
Late decelerations with minimal variability indicate fetal hypoxia requiring immediate intervention. Positioning left lateral and administering oxygen improves uteroplacental blood flow and oxygenation. Other options are not priority actions in this acute scenario.
Clinical Judgment
The key to this problem is recognizing the signs of fetal hypoxia and improving the fetal condition through immediate, non-invasive measures. Late Decelerations are a pattern that begins after the peak of a uterine contraction and returns to baseline only after the contraction ends, indicating Uteroplacental Insufficiency. When accompanied by Minimal Variability, this suggests that the fetus's compensatory reserves are depleted, making severe hypoxia and potential acidosis highly likely. In this situation, the nurse's priority is to address the cause (reduced uterine blood flow) and maximize fetal oxygen supply. Left lateral positioning immediately improves maternal cardiac output and uterine blood flow by reducing compression of the inferior vena cava, while oxygen administration increases maternal oxygen saturation and enhances oxygen delivery to the fetus. This is the First-line Intervention to attempt before Delivery.
Memory Tip
Remember late decelerations and minimal variability as "Late & Low = Lateral & O2". When you see Late decelerations with Low variability, the first response is Lateral positioning and Oxygen.
KR vs US
In both Korea and the US, late decelerations are recognized as an abnormal pattern requiring immediate intervention. In the US NGN exam, the CJMM (Clinical Judgment Measurement Model) emphasizes the flow of "Recognize-Analyze-Respond-Evaluate." This question is a typical pattern asking for the "Priority Action" after "Recognizing Cues." While similar responses occur in Korean practice, the US exam evaluates position change and oxygen administration as the most immediate and direct priority actions over other essential interventions like discontinuing oxytocin, administering fluids, or notifying the physician.
임상 시나리오
Clinical Practice Guide
When late decelerations are observed, remember and implement interventions using the "IDOUS" mnemonic.
- Interrupt Oxytocin
- Discontinue Labor Stimulants
- Oxygen via non-rebreather mask
- Uteroplacental Perfusion increase (left lateral position, fluid administration)
- Specialist Notification (immediately report to physician/obstetrician)
Caution
Be careful of traps in SATA (Select All That Apply) questions. If asked to "select all interventions for late decelerations," less relevant options like "fetal scalp stimulation assessment" or "check maternal temperature" may be included along with the IDOUS interventions above. When the cause of late decelerations is clearly uteroplacental insufficiency, fetal scalp stimulation is not an appropriate intervention. Also, oxytocin is discontinued only when contractions are tachysystole, so you must read the question context accurately.
핵심 개념
Late Decelerations — Late deceleration. A gradual decrease in fetal heart rate that begins after the peak of a uterine contraction and returns to baseline after the contraction ends. A sign of uteroplacental insufficiency and fetal hypoxia.
Minimal Variability — Minimal variability. A condition where the amplitude fluctuations of the fetal heart rate baseline are less than 5 beats per minute. It may indicate fetal central nervous system depression, sleep cycles, or hypoxia/acidosis. It is particularly concerning when accompanied by late decelerations.
Uteroplacental Insufficiency — Uteroplacental insufficiency. A condition in which the placenta fails to supply sufficient oxygen and nutrients needed for fetal growth and development. A major cause of late decelerations.
Left Lateral Position — Left lateral position. A position adopted when there are signs of fetal hypoxia during labor. It reduces the pressure of the uterus on the inferior vena cava and aorta, thereby increasing maternal cardiac output and uteroplacental blood flow.
Non-rebreather Mask — Non-rebreather mask. An oxygen delivery device with a reservoir bag and one-way valve to prevent the patient from rebreathing exhaled air. It can supply high-concentration oxygen (10-15 L/min, FiO2 approximately 80-90%) and is used to improve maternal-fetal oxygenation during labor.