# A nurse is monitoring a laboring client at 38 weeks gestation. The fetal heart rate (FHR) tracing shows a baseline of 110 bpm with moderate variability. During the last three contractions, the nurse observes late decelerations that begin after the peak of the contraction and return to baseline after the contraction ends. What is the nurse's priority action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542997  
> 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 moderate variability. During the last three contractions, the nurse observes late decelerations that begin after the peak of the contraction and return to baseline after the contraction ends. What is the nurse's priority action?

## 보기

1. Immediately notify the healthcare provider and prepare for potential emergency delivery **✔ 정답**
2. Reposition the client to left lateral position and continue monitoring
3. Increase the IV fluid rate and administer oxygen via face mask
4. Document the findings and reassess the FHR pattern in 15 minutes

**정답: 1**

## 해설

Late decelerations indicate uteroplacental insufficiency and fetal hypoxia, requiring immediate notification of the healthcare provider for potential emergency delivery. Other options are supportive measures but do not address the urgency of this ominous pattern.

## 심화 해설

Clinical Judgment
The key to this question is understanding the clinical significance of Late Deceleration and determining the appropriate timing for Notify HCP!. When analyzing fetal heart rate patterns, you must apply the Category system. While a normal baseline (110 bpm) and moderate variability are positive factors, recurrent late decelerations are a **warning sign that a Category II pattern can deteriorate into a Category III pattern**. Late deceleration itself signifies uteroplacental insufficiency, which is a fundamental problem that cannot be corrected without immediate medical intervention. The nurse's priority is to identify and report the problem so the healthcare provider can comprehensively evaluate the fetal status (e.g., fetal scalp stimulation, blood gas analysis) and, if necessary, decide on an **emergency delivery**.

Memory Tip:
Remember late decelerations as "**L**ate for **L**ife-threatening" or "**U** for **U**teroplacental problem." If the pattern is recurrent and does not respond to corrective measures (position change, oxygen administration, fluid bolus), reporting must be done **immediately**.

KR vs US
In Korea, the principle is to report to the physician immediately when late decelerations occur, but depending on the situation, preliminary actions (position change, oxygen administration) may be performed first and observed. However, in the NGN/US approach, **recurrent late decelerations are clearly defined as a 'non-reassuring' element within a Category II pattern, a situation requiring immediate medical evaluation**. Continuing observation based on the nurse's independent judgment is not appropriate.

## 임상 시나리오

Clinical Practice Guide
The standard protocol when a late deceleration is identified is as follows:
1.  **Immediately** reposition the mother to the left lateral position (to reduce inferior vena cava compression).
2.  Open intravenous fluids (hyperstimulation may be the cause).
3.  Administer oxygen at 10L/min via a non-rebreather mask.
4.  Immediately report to the healthcare provider (HCP).
5.  Prepare for additional measures (e.g., tocolytic administration) or emergency delivery as directed by the medical team.

Caution:
In SATA (Select All That Apply) questions asking for the nurse's "**initial** actions," you must select all independent interventions performed **before** reporting to the physician (position change, oxygen administration, stopping/increasing IV fluids). However, if the question asks for the "**priority** action," as in this case, you must select the most urgent and critical action that addresses the risk: **"immediately notify the medical team."** The preceding interventions are performed **concurrently with or immediately after** the report.

## 핵심 개념

- **Late Deceleration (지연 감속)** — A deceleration of the fetal heart rate that begins after the peak of a uterine contraction and returns to baseline after the contraction ends. This is a non-reassuring pattern suggestive of uteroplacental insufficiency.
- **Uteroplacental Insufficiency (자궁태반 기능 부전)** — A condition where the function of the placenta, which is responsible for supplying oxygen and nutrients from the mother to the fetus, is reduced. It is a major pathophysiological cause of late decelerations.
- **Category II FHR Pattern (카테고리 II 태아심박수 패턴)** — An indeterminate pattern, neither normal (Category I) nor abnormal (Category III). If late decelerations appear repeatedly, it can rapidly progress to Category III, requiring special attention and evaluation by medical staff.
- **Intrauterine Resuscitation (자궁 내 소생술)** — A series of measures taken to improve fetal condition when fetal distress is suspected. These include repositioning to the left lateral position, oxygen administration, fluid supply, and tocolytic administration. This is a measure to buy time for medical intervention.
- **Electronic Fetal Monitoring (EFM) (전자 태아 모니터링)** — A tool that continuously records fetal heart rate and uterine contractions during labor to assess fetal well-being and uterine activity. Pattern interpretation is an important clinical judgment skill for nurses.

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