# A nurse is monitoring a laboring client and observes the following fetal heart rate (FHR) pattern: baseline FHR of 140 bpm, moderate variability, and recurrent late decelerations with each contraction. What is the most appropriate initial nursing action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542990 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is monitoring a laboring client and observes the following fetal heart rate (FHR) pattern: baseline FHR of 140 bpm, moderate variability, and recurrent late decelerations with each contraction. What is the most appropriate initial nursing action? ## 보기 1. Increase the oxytocin infusion rate to strengthen contractions 2. Encourage the client to push with the next contraction 3. Document the findings and continue monitoring 4. Change the client's position to left lateral and administer oxygen **✔ 정답** **정답: 4** ## 해설 Late decelerations indicate uteroplacental insufficiency and fetal hypoxia. Immediate interventions include left lateral positioning and oxygen administration to improve fetal oxygenation. Other options are inappropriate as they may worsen the situation. ## 심화 해설 Understanding the Fetal Heart Rate Pattern The tracing shows a baseline FHR of 140 bpm with moderate variability, which indicates a well-oxygenated fetal central nervous system at that moment. However, the presence of recurrent late decelerations changes the clinical picture significantly. Late decelerations are characterized by a gradual decrease in FHR that begins after the peak of a contraction and returns to baseline well after the contraction ends. This pattern reflects transient uteroplacental insufficiency, where the delivery of oxygen to the fetus is temporarily compromised during uterine contractions. The combination of recurrent late decelerations, even with a normal baseline and moderate variability, signals a progressive deterioration in fetal oxygenation that can lead to fetal acidemia if not corrected. The study by Tomich et al. highlights the critical role of intrapartum cardiotocography in identifying such at-risk patterns, as the goal is to intervene before fetal acidemia develops . Prioritizing Intrauterine Resuscitation When late decelerations are identified, the most appropriate initial nursing action is to implement intrauterine resuscitation measures. These interventions aim to improve maternal blood flow to the placenta and increase fetal oxygenation. The correct choice is to change the client's position to left lateral and administer oxygen. The left lateral position displaces the gravid uterus off the maternal vena cava and aorta, promoting venous return, increasing cardiac output, and maximizing uteroplacental blood flow. Administering supplemental oxygen via a non-rebreather mask at 8-10 L/min increases the maternal oxygen gradient, enhancing oxygen transfer to the fetus. These actions directly address the underlying pathophysiology of uteroplacental insufficiency and are foundational steps in managing a category II or III FHR tracing, as discussed in the review by Tsikouras et al. regarding the critical role of CTG in assessing fetal well-being and guiding labor management . Analyzing the Incorrect Options The other options are contraindicated or insufficient for this clinical scenario. Increasing the oxytocin infusion rate would intensify the frequency and strength of uterine contractions, which would further reduce the intermittent oxygen supply to an already compromised fetus, worsening the hypoxic stress and accelerating the progression to acidemia. Encouraging the client to push is inappropriate because the fetal intolerance to labor indicates that delivery is not imminent or safe without first attempting resuscitation; pushing would also transiently decrease maternal oxygenation and placental perfusion. While documenting and continuing to monitor is a necessary component of nursing care, it is a passive action in the face of an abnormal FHR pattern. The priority is to act immediately to reverse the hypoxic insult, not merely to observe its progression. The goal, as supported by the evidence on CTG's role in predicting fetal acidemia, is to use the tracing as a real-time screening tool that prompts timely intervention to prevent a poor neonatal outcome [1,2]. ## 임상 시나리오 Clinical Practice Guide: Late Decelerations Assessment - Identify recurrent late decelerations: gradual FHR decrease beginning after contraction peak, returning to baseline after contraction ends. - Evaluate baseline FHR and variability; moderate variability suggests current CNS oxygenation but recurrent late decelerations indicate progressive uteroplacental insufficiency. - Assess uterine contraction pattern (frequency, duration, intensity) and maternal vital signs. Immediate Interventions - Reposition client to left lateral (or right lateral if left is not tolerated) to relieve aortocaval compression and maximize cardiac output. - Administer oxygen at 8-10 L/min via non-rebreather face mask to increase maternal-fetal oxygen gradient. - Discontinue or reduce oxytocin infusion to decrease uterine activity and improve placental perfusion. - Administer IV fluid bolus (e.g., 500-1000 mL Lactated Ringer's) as ordered to expand intravascular volume. - Notify the healthcare provider of persistent late decelerations despite intrauterine resuscitation. Ongoing Monitoring - Continuously monitor FHR and uterine activity for resolution of late decelerations. - Assess maternal blood pressure, heart rate, and oxygen saturation every 5-15 minutes during acute event. - Document interventions, maternal-fetal response, and communication with provider. - Prepare for possible expedited delivery if late decelerations persist and fetal acidemia is suspected. ## 핵심 개념 - **Late Decelerations** — Gradual decreases in fetal heart rate that begin after the peak of a contraction and return to baseline after the contraction ends, indicating uteroplacental insufficiency. - **Intrauterine Resuscitation** — Nursing measures such as maternal repositioning, oxygen administration, and IV fluid bolus to improve fetal oxygenation and placental perfusion. - **Moderate Variability** — Fluctuations in the baseline fetal heart rate of 6 to 25 bpm, indicating an intact and well-oxygenated fetal autonomic nervous system. ## 같은 주제 문제 - [A nurse is monitoring a laboring client with continuous electronic fetal monitoring. The f…](https://mymerci.kr/pages/nclex_q.php?qn_id=542988) - [A nurse is monitoring a laboring client and observes the following fetal heart rate (FHR) …](https://mymerci.kr/pages/nclex_q.php?qn_id=542989) - [A nurse is monitoring a 32-year-old primigravida at 39 weeks gestation and observes the fo…](https://mymerci.kr/pages/nclex_q.php?qn_id=542991) - [A nurse is monitoring a laboring client with continuous electronic fetal monitoring at 40 …](https://mymerci.kr/pages/nclex_q.php?qn_id=542992) - [A nurse is monitoring a laboring client with continuous electronic fetal monitoring. The f…](https://mymerci.kr/pages/nclex_q.php?qn_id=542993) - [A nurse is monitoring a laboring client at 38 weeks gestation. The fetal heart rate (FHR) …](https://mymerci.kr/pages/nclex_q.php?qn_id=542994) - [A nurse is monitoring a laboring client at 40 weeks gestation. The fetal heart rate tracin…](https://mymerci.kr/pages/nclex_q.php?qn_id=542995) - [A nurse is monitoring a laboring client at 36 weeks gestation. The fetal heart rate tracin…](https://mymerci.kr/pages/nclex_q.php?qn_id=542996) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._