# A nurse is monitoring a laboring client with continuous electronic fetal monitoring at 40 weeks gestation. The fetal heart rate tracing shows a baseline of 140 bpm with moderate variability. Suddenly, the nurse observes repetitive late decelerations with each contraction over the past 10 minutes. What is the most appropriate immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542992 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is monitoring a laboring client with continuous electronic fetal monitoring at 40 weeks gestation. The fetal heart rate tracing shows a baseline of 140 bpm with moderate variability. Suddenly, the nurse observes repetitive late decelerations with each contraction over the past 10 minutes. What is the most appropriate immediate nursing intervention? ## 보기 1. Position the client supine, administer oxygen at 2 L/min via nasal cannula, and notify the provider. 2. Continue monitoring and document the findings, as this is a reassuring pattern in labor. 3. Position the client on her left side, administer oxygen at 8-10 L/min via face mask, and notify the healthcare provider immediately. **✔ 정답** 4. Increase the IV fluid rate, encourage ambulation, and apply a face mask at 8 L/min. **정답: 3** ## 해설 Late decelerations indicate uteroplacental insufficiency and fetal hypoxia. Immediate nursing intervention includes left lateral positioning, oxygen administration, and notifying the provider. Other options are incorrect or insufficient. ## 심화 해설 Understanding the Clinical Scenario The fetal heart rate (FHR) tracing described—a baseline of 140 bpm with moderate variability—initially indicates a well-oxygenated fetus with an intact autonomic nervous system. However, the sudden onset of repetitive late decelerations over a 10-minute period signals a critical change. Late decelerations are a hallmark of uteroplacental insufficiency, where the fetus experiences transient hypoxemia during uterine contractions because the placenta cannot adequately deliver oxygen [1,3]. This pattern is classified as a non-reassuring fetal heart rate status (NRFHRS), a key predictor of fetal hypoxia and metabolic acidosis, which are major contributors to perinatal morbidity and mortality . Analysis of the Correct Intervention The most appropriate immediate nursing intervention is to position the client on her left side, administer oxygen at 8-10 L/min via a non-rebreather face mask, and notify the healthcare provider immediately. Pathophysiological Rationale and Nursing Actions - Left Lateral Positioning: Placing the client in a supine position can cause the gravid uterus to compress the maternal aorta and inferior vena cava, a condition known as supine hypotensive syndrome. This compression reduces venous return, maternal cardiac output, and ultimately, blood flow to the placenta. Repositioning to the left side displaces the uterus off these major vessels, maximizing uteroplacental perfusion and oxygen delivery to the fetus [1,3]. - High-Flow Oxygen Administration: Administering oxygen at 8-10 L/min via a tight-fitting face mask is essential to increase the maternal partial pressure of oxygen. This creates a diffusion gradient that enhances the transfer of dissolved oxygen to the fetus through the compromised placenta, directly addressing the suspected fetal hypoxemia that causes the late decelerations . A nasal cannula at 2 L/min is insufficient for this acute resuscitation. - Immediate Provider Notification: Repetitive late decelerations constitute an obstetrical emergency that may necessitate expedited delivery if intrauterine resuscitation measures fail. Prompt notification allows the provider to assess the situation, interpret the tracing, and prepare for potential operative interventions to prevent adverse neonatal outcomes [1,3]. Why Other Options Are Incorrect - Option 1 is incorrect because positioning the client supine would worsen placental perfusion by compressing the vena cava and aorta. Additionally, the prescribed oxygen delivery method and flow rate are inadequate for acute fetal resuscitation. - Option 2 is incorrect and dangerous. Repetitive late decelerations are never a reassuring pattern; they are a definitive sign of fetal compromise requiring immediate intervention, not just continued observation [1,3]. - Option 4 is incorrect. While a bolus of IV fluids is a common intrauterine resuscitation measure to expand maternal circulating volume and improve placental blood flow, encouraging ambulation is contraindicated. A client with a non-reassuring FHR tracing requires continuous monitoring and should not be ambulating, as this could further stress the fetus and delays critical interventions . ## 임상 시나리오 Clinical Practice Guide: Managing Repetitive Late Decelerations Rapid Recognition - Identify the pattern: FHR decelerations that are uniform in shape, begin after the peak of the contraction, and return to baseline after the contraction ends. - Quantify the change: Repetitive late decelerations occurring with more than 50% of contractions over a 10-minute window signal non-reassuring fetal status. - Assess baseline variability: Moderate variability present with late decelerations suggests the fetus is still compensating but requires immediate intervention to prevent decompensation and acidosis. Step-by-Step Intrauterine Resuscitation - **Maternal Repositioning:** Immediately turn the client to a left lateral position. If that is not possible, a right lateral or hands-and-knees position can be used. This displaces the uterus off the vena cava and aorta, improving venous return and placental perfusion. - **Oxygen Administration:** Apply a non-rebreather face mask at 8-10 L/min. High-flow oxygen increases the maternal oxygen gradient, enhancing oxygen delivery to the fetus. Discontinue oxygen once the tracing normalizes to avoid potential free radical injury. - **Provider Notification:** Notify the healthcare provider immediately with a concise SBAR report including current FHR pattern, maternal vital signs, and interventions initiated. Prepare for potential expedited delivery if the pattern does not resolve. - **IV Fluid Bolus:** If ordered, administer a bolus of isotonic crystalloid (e.g., 500-1000 mL Lactated Ringer's) to expand maternal intravascular volume and improve uterine blood flow. - **Adjunct Measures:** Discontinue oxytocin if infusing to reduce uterine hyperstimulation. Correct maternal hypotension with IV fluids or ephedrine as prescribed. Ongoing Assessment and Documentation - Continuously monitor FHR and uterine activity for resolution of late decelerations and return to reassuring status. - Document the time of onset, description of the decelerations, interventions performed, maternal response, and provider notification. - If decelerations persist despite interventions, anticipate the need for cesarean delivery and prepare the client and equipment accordingly. ## 핵심 개념 - **Late Decelerations** — FHR decelerations that begin after the peak of a contraction and return to baseline after the contraction ends, indicating uteroplacental insufficiency. - **Uteroplacental Insufficiency** — A decrease in blood flow and oxygen exchange across the placenta, compromising fetal oxygenation during contractions. - **Intrauterine Resuscitation** — Immediate interventions such as maternal repositioning, oxygen administration, and IV fluid bolus to improve fetal oxygenation. - **Supine Hypotensive Syndrome** — Compression of the vena cava and aorta by the gravid uterus in the supine position, reducing maternal cardiac output and placental perfusion. ## 같은 주제 문제 - [A nurse is monitoring a laboring client with continuous electronic fetal monitoring. 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