# A nurse is monitoring a 32-year-old primigravida at 39 weeks gestation 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542991  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A nurse is monitoring a 32-year-old primigravida at 39 weeks gestation 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?

## 보기

1. Change the client's position to left lateral and administer oxygen via face mask at 8-10 L/min **✔ 정답**
2. Increase the IV fluid rate and prepare for immediate cesarean delivery
3. Discontinue oxytocin infusion and notify the healthcare provider
4. Perform a vaginal examination to assess for cord prolapse

**정답: 1**

## 해설

Variable decelerations with slow return and minimal variability suggest severe cord compression. Immediate actions are position change and oxygen to improve fetal oxygenation. Other options are not first-line interventions.

## 심화 해설

Analysis of the Fetal Heart Rate Pattern

The fetal heart rate (FHR) tracing described presents a concerning clinical picture that requires immediate intervention. The baseline FHR of 140 bpm is within the normal range. However, the tracing demonstrates three critical abnormal features simultaneously: recurrent variable decelerations, a slow return to baseline, and minimal variability.

Recurrent variable decelerations are abrupt decreases in the FHR, typically caused by umbilical cord compression. In this scenario, the depth of the decelerations dropping to 70 bpm and their prolonged duration of 60-90 seconds indicate significant fetal stress. The most worrisome characteristic is the slow return to baseline, which suggests that the fetus is experiencing a degree of hypoxic stress and is struggling to recover between contractions. When this is combined with minimal variability—a direct indicator of fetal metabolic acidosis and central nervous system depression—the pattern becomes a strong predictor of ongoing fetal hypoxia and potential acidemia [1].

Rationale for the Correct Answer

The most appropriate immediate nursing action is to change the client's position to left lateral and administer oxygen via face mask at 8-10 L/min. This choice directly applies the first-line, non-invasive intrauterine resuscitation measures designed to improve fetal oxygenation and resolve umbilical cord compression [1].

The physiological basis for this intervention is twofold. First, repositioning the mother to a left lateral position displaces the gravid uterus off the inferior vena cava and aorta, maximizing uteroplacental blood flow and cardiac output. For variable decelerations specifically, position changes can also physically alter the relationship between the umbilical cord, the fetus, and the uterine wall, potentially relieving the cord compression that is causing the abrupt decelerations. Second, administering high-flow oxygen by non-rebreather face mask increases the maternal partial pressure of oxygen, creating a diffusion gradient that enhances oxygen transfer to the fetus via the placenta. This intervention is a standard, evidence-based component of intrauterine resuscitation for suspicious or pathological cardiotocographic (CTG) patterns [1].

Why Other Options Are Incorrect

- Option 2 (Increase the IV fluid rate and prepare for immediate cesarean delivery): While increasing IV fluid is a supportive measure for maternal hypotension and can improve intravascular volume, it is not the most targeted first-line intervention for variable decelerations caused by cord compression. Preparing for an immediate cesarean delivery is premature. The nurse must first implement bedside resuscitative measures to see if the pattern resolves. If the pattern does not improve with position change and oxygen, then escalation to operative delivery becomes the priority. Jumping to surgical preparation without attempting simpler, faster interventions is not the correct sequence of nursing action.

- Option 3 (Discontinue oxytocin infusion and notify the healthcare provider): Discontinuing oxytocin is a critical intervention for patterns associated with uterine tachysystole, such as late decelerations or prolonged decelerations. However, the problem does not state that the patient is receiving oxytocin. The described pattern is specifically that of recurrent variable decelerations, which are caused by cord compression, not excessive uterine activity. While notifying the provider is always a component of care, it is not the most immediate action before a hands-on nursing intervention is performed.

- Option 4 (Perform a vaginal examination to assess for cord prolapse): A vaginal examination to rule out cord prolapse is an important consideration when variable decelerations appear suddenly, especially after rupture of membranes. However, the question does not provide a history of recent membrane rupture, nor does it describe a sudden onset of a new, profound deceleration. The pattern is described as "recurrent," suggesting an established pattern. The priority is to first attempt to resolve the cord compression through maternal repositioning, which is a less invasive and faster intervention. A vaginal examination would be indicated if the pattern did not resolve with position changes or if there were other risk factors for prolapse present.References (research sources)

- [1]Link Between Non-Invasive Intrapartum Interventions and Cardiotocography Patterns, Amniotic Fluid Color, and Immediate Neonatal Outcomes.Research articleGarcia-Cuadrado N, Fernandez-Araque A, Verde Z, Sainz-Gil M, Durantez-Fernandez C, Cardaba-Garcia RM, Velasco-Gonzalez V. (2026) · DOI: 10.3390/healthcare14070888

## 임상 시나리오

A 32-year-old primigravida at 39 weeks gestation presents with a fetal heart rate (FHR) tracing showing a baseline of 140 bpm, recurrent variable decelerations to 70 bpm lasting 60-90 seconds with a slow return to baseline, and minimal variability. The nurse's immediate action is to initiate intrauterine resuscitation.

Clinical Management Steps

- **Reposition the Patient:** Turn the client to the left lateral position to relieve aortocaval compression and potentially reduce umbilical cord compression. If no improvement, consider right lateral, knee-chest, or Trendelenburg positions.

- **Administer Oxygen:** Apply a non-rebreather face mask at 8-10 L/min to maximize maternal oxygen saturation and enhance oxygen delivery to the fetus. Discontinue once the FHR pattern resolves to avoid potential free radical injury.

- **Increase IV Fluid Rate:** Bolus with isotonic crystalloid (e.g., Lactated Ringer's or 0.9% Normal Saline) to expand maternal intravascular volume and improve uteroplacental perfusion.

- **Assess for and Discontinue Uterotonics:** If an oxytocin infusion is running, discontinue it immediately to reduce uterine hyperstimulation, a potential cause of cord compression.

- **Notify the Provider:** After initiating these first-line measures, promptly inform the obstetrician or midwife. If the pattern persists, prepare for potential operative delivery.

Key Considerations

- Perform a vaginal examination to rule out cord prolapse, especially if decelerations are new or severe, but only after or concurrently with initial resuscitation efforts.

- Document all interventions, maternal vital signs, and the FHR response every 5-15 minutes.

- If minimal variability persists with recurrent decelerations, anticipate the need for expedited delivery as this pattern suggests fetal acidemia.

## 핵심 개념

- **Variable Decelerations (가변 감속)** — Fetal heart rate that suddenly drops and then quickly recovers. The shape varies ("variable"), and it mainly occurs due to umbilical cord compression. Severity is assessed by the depth of the deceleration, duration, and speed of return to baseline.
- **Category III FHR Pattern (비정상 태아심박수 패턴)** — Pattern showing one of the following: 1) absent baseline variability, 2) recurrent late decelerations, 3) recurrent variable decelerations + decreased/absent baseline variability or arrhythmia, etc. This is associated with fetal hypoxic acidosis and requires immediate evaluation and intervention.
- **Intrauterine Resuscitation (자궁내 소생술)** — A series of non-invasive interventions performed to improve fetal condition when fetal distress is suspected. It can be remembered with D.O.T.A.P. (Discontinue oxytocin, Oxygen administration, Turn mother (position change), Assess for causes, Provide IV fluids), etc.
- **Minimal Variability (최소 변동성)** — Fetal heart rate baseline variability with amplitude fluctuations of less than 5 beats per minute. This may be associated with fetal sleep cycles, medications, but most concerning is fetal hypoxia/acidosis. It is particularly dangerous when accompanied by other abnormal patterns.
- **Cord Compression (제대 압박)** — A condition where the umbilical cord becomes trapped between fetal body parts, the uterine wall, or the pelvis, blocking blood flow. This causes variable decelerations. Treatment focuses on relieving the compression, with the most common initial intervention being maternal repositioning.

## 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 laboring client and observes the following fetal heart rate (FHR) …](https://mymerci.kr/pages/nclex_q.php?qn_id=542990)
- [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._