# A nurse is monitoring a laboring client at 38 weeks gestation. The fetal heart rate (FHR) tracing shows a baseline of 110 bpm with minimal variability and late decelerations occurring with each contraction. The client's contractions are every 2-3 minutes, lasting 60-90 seconds. What is the nurse's priority action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542994  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A nurse is monitoring a laboring client at 38 weeks gestation. The fetal heart rate (FHR) tracing shows a baseline of 110 bpm with minimal variability and late decelerations occurring with each contraction. The client's contractions are every 2-3 minutes, lasting 60-90 seconds. What is the nurse's priority action?

## 보기

1. Change the client's position to left lateral and administer oxygen via face mask at 8-10 L/min
2. Discontinue oxytocin if infusing and notify the healthcare provider immediately
3. Prepare for immediate cesarean delivery and notify the surgical team **✔ 정답**
4. Increase IV fluid rate and perform vaginal examination to assess cervical dilation

**정답: 3**

## 해설

Late decelerations with minimal variability indicate severe fetal compromise requiring immediate delivery. Other interventions like position change or oxygen are insufficient in this scenario.

## 심화 해설

Clinical Context

This fetal heart rate (FHR) tracing demonstrates a category III pattern according to the three-tiered system recognized by the American College of Obstetricians and Gynecologists (ACOG). The combination of a baseline of 110 bpm, minimal variability, and recurrent late decelerations in the setting of frequent, prolonged contractions indicates a high likelihood of ongoing fetal hypoxic stress and metabolic acidemia. Category III tracings are abnormal and require prompt evaluation and intervention.

Pathophysiology of the Tracing

Late decelerations are a reflex response to transient fetal hypoxemia during uterine contractions. In a compromised fetus, contractions compress the spiral arteries, reducing uteroplacental blood flow and oxygen delivery. If the fetus has diminished placental reserve, this intermittent hypoxia leads to a shift toward anaerobic metabolism and the accumulation of organic acids, reflected by a rising fetal extracellular base deficit (BDecf). The minimal variability observed is a direct consequence of central nervous system depression caused by metabolic acidemia, indicating that the fetal brain is no longer adequately regulating the autonomic nervous system's influence on heart rate. This progression from late decelerations to minimal variability signals a transition from a compensated hypoxic state to a decompensated one, where the risk of permanent brain injury escalates .

Analysis of the Priority Action

The nurse's priority is to expedite delivery to terminate the hypoxic insult. The rationale for each option is as follows:

- Option 1 (Incorrect): Changing maternal position to left lateral and administering oxygen are intrauterine resuscitation techniques appropriate for category II tracings where the goal is to improve fetal oxygenation and allow labor to continue. However, this tracing is category III, signifying a more severe and immediate threat. While these measures can be initiated while preparing for surgery, they are not the definitive priority action and should not delay delivery. Research on category II tracings highlights that the timing of intervention is critical to prevent the base deficit from reaching a threshold associated with severe metabolic acidemia and brain injury; in a category III tracing, that threshold is imminent or has been crossed .

- Option 2 (Incorrect): Discontinuing oxytocin is a critical first step to reduce uterine hyperstimulation, which can cause late decelerations. However, the contractions described (every 2-3 minutes, lasting 60-90 seconds) may or may not be tachysystole, and the tracing has already progressed to minimal variability. Simply stopping oxytocin and notifying the provider does not constitute the most immediate, life-saving intervention. The priority is to move directly to the definitive treatment, which is delivery.

- Option 3 (Correct): The presence of a category III FHR tracing with minimal variability and recurrent late decelerations indicates that fetal metabolic acidemia is likely already significant. The study by Nakao et al. underscores that the progression of fetal extracellular base deficit during abnormal tracings is a time-critical factor; delays in intervention directly correlate with a higher risk of severe fetal metabolic acidemia and subsequent cerebral palsy . Therefore, the nurse must recognize that intrauterine resuscitation alone is insufficient and prepare for an immediate cesarean delivery to physically remove the fetus from the hypoxic environment.

- Option 4 (Incorrect): Increasing the IV fluid rate is an intrauterine resuscitative measure that can improve maternal cardiac output and uteroplacental perfusion. A vaginal examination is performed to rule out a rapid vaginal delivery. However, these actions are secondary to the immediate need to prepare for a cesarean section. The tracing pattern is not consistent with a benign cause that would resolve with fluids or imminent vaginal birth; it is a pattern of decompensating fetal acidemia requiring surgical intervention.

## 임상 시나리오

Clinical Scenario

A laboring client at term presents with a Category III fetal heart rate tracing: baseline 110 bpm, minimal variability, recurrent late decelerations, and tachysystole. This pattern signifies severe fetal hypoxic stress and metabolic acidemia, necessitating immediate intervention.

Immediate Nursing Actions

- **Activate the chain of command:** Notify the obstetric provider and charge nurse simultaneously while initiating preparations for an emergency cesarean delivery. Do not delay for further intrauterine resuscitation.

- **Prepare the client and operating room:** Initiate preoperative checklist (consent verification, surgical site marking, removal of jewelry/dentures), insert an indwelling urinary catheter, and administer a preoperative antibiotic as ordered.

- **Coordinate the surgical team:** Call for anesthesia, a neonatal resuscitation team, and additional nursing staff. The decision-to-incision interval should be as short as possible, ideally within 30 minutes.

- **Provide maternal support:** Explain the urgency to the client and support person using clear, calm language. Maintain emotional support while rapidly executing clinical tasks.

Intrauterine Resuscitation While Preparing for Delivery

While the definitive treatment is delivery, these measures can be performed concurrently to optimize fetal status:

- Position the client in a left lateral or complete lateral position to relieve aortocaval compression.

- Administer a 500-1000 mL IV fluid bolus of lactated Ringer's solution to improve uteroplacental perfusion.

- Discontinue oxytocin infusion to reduce uterine contraction frequency and intensity.

- Administer oxygen via a non-rebreather face mask at 10 L/min to increase maternal oxygen reserve.

These resuscitation measures do not replace the need for emergent delivery. They are temporizing actions to improve fetal oxygenation while the surgical team assembles.

Documentation and Communication

- Document the FHR tracing interpretation, interventions performed, maternal and fetal response, and time of provider notification.

- Use SBAR (Situation, Background, Assessment, Recommendation) format when communicating with the provider: "I am calling about a Category III tracing with minimal variability and recurrent late decelerations. I have initiated intrauterine resuscitation and we need to proceed with an emergency cesarean delivery immediately."

## 핵심 개념

- **Category III FHR Tracing** — An abnormal fetal heart rate pattern including absent variability with recurrent late/variable decelerations or bradycardia, indicating high risk of fetal acidemia and requiring prompt evaluation and intervention.
- **Late Decelerations** — A gradual decrease in FHR with onset after the contraction begins and return to baseline after the contraction ends, caused by uteroplacental insufficiency leading to fetal hypoxemia.
- **Minimal Variability** — Fluctuations in the baseline FHR of less than 5 bpm, indicating fetal central nervous system depression often due to metabolic acidemia.
- **Fetal Acidemia** — Increased hydrogen ion concentration in fetal blood (pH < 7.20) resulting from anaerobic metabolism due to prolonged hypoxic stress, leading to metabolic acidosis.
- **Uteroplacental Insufficiency** — A decline in placental function that reduces oxygen and nutrient transfer to the fetus, commonly manifested as late decelerations on FHR monitoring.

## 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 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 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._