# A primigravida client at 40 weeks gestation is in active labor. Her cervix is 6 cm dilated, 100% effaced, and the fetal head is at -1 station. The fetal heart rate shows late decelerations with each contraction. What is the nurse's priority action?

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> subject: Maternal Newborn Health

## 문제

A primigravida client at 40 weeks gestation is in active labor. Her cervix is 6 cm dilated, 100% effaced, and the fetal head is at -1 station. The fetal heart rate shows late decelerations with each contraction. What is the nurse's priority action?

## 보기

1. Encourage the client to change positions frequently
2. Increase the rate of intravenous fluid administration
3. Notify the healthcare provider immediately **✔ 정답**
4. Apply oxygen via nasal cannula at 2 L/min

**정답: 3**

## 해설

Late decelerations indicate uteroplacental insufficiency and fetal hypoxia, requiring immediate provider notification for potential emergency intervention. Supportive measures like position change, IV fluids, or oxygen are secondary priorities.

## 심화 해설

Understanding the Clinical Scenario

The client is a primigravida at term in active labor. The cervical examination reveals dilation of 6 cm, complete effacement of 100%, and a fetal station of -1. The critical assessment finding is the presence of late decelerations in the fetal heart rate (FHR) with each contraction.

Decoding the Pathophysiology: Why Late Decelerations Are an Emergency

A late deceleration is a visually apparent, gradual decrease in the FHR that begins after the peak of a uterine contraction and returns to baseline after the contraction ends. This pattern is not a benign response to head compression or cord occlusion; it is a sign of uteroplacental insufficiency. The underlying mechanism is a transient interruption in fetal oxygenation during the contraction. In a compromised fetus, the placental reserve is insufficient to maintain adequate gas exchange when uterine blood flow is reduced during a contraction, leading to fetal hypoxemia. This hypoxemia triggers a chemoreceptor-mediated reflex that slows the fetal heart rate. The consistent recurrence of late decelerations indicates that the fetus is experiencing progressive metabolic acidosis from repeated hypoxic insults, a condition directly linked to non-reassuring fetal heart rate status (NRFHRS), which is a major contributor to perinatal mortality and morbidity [2].

Analyzing the Priority Action Using the Nursing Process

The NCLEX-RN prioritizes actions based on the urgency of the clinical situation. The presence of recurrent late decelerations signifies a Category III FHR tracing, which is abnormal and predictive of fetal hypoxia and metabolic acidosis [2]. This situation requires immediate intervention to resolve the underlying cause and expedite delivery if unresolved. The nurse's scope of practice includes implementing intrauterine resuscitative measures, but the most critical step is to communicate this emergent finding to a provider who can make definitive decisions, such as performing an emergency cesarean delivery. A systematic review and meta-analysis confirms that NRFHRS is a significant predictor of adverse immediate neonatal outcomes, underscoring the need for rapid escalation of care [3].

Let's evaluate the options in order of priority:

- Option 3 (Notify the healthcare provider immediately): This is the priority action. The provider must be informed without delay to evaluate the need for operative delivery. While the nurse initiates other interventions, the provider's arrival and decision-making are the ultimate determinants of outcome. Delaying this notification while performing other tasks jeopardizes fetal safety.

- Option 1 (Encourage the client to change positions frequently): This is an essential intrauterine resuscitative measure. Changing position to a lateral recumbent position can relieve aortocaval compression, improving maternal cardiac output and uterine blood flow. However, it is a nursing intervention that should be performed in conjunction with, not before, notifying the provider. It does not replace the need for immediate escalation.

- Option 2 (Increase the rate of intravenous fluid administration): Administering a bolus of isotonic IV fluid is another standard resuscitative measure to expand maternal intravascular volume and enhance placental perfusion. Like position changes, this is a supportive intervention that the nurse should initiate but is secondary to the priority of summoning the provider.

- Option 4 (Apply oxygen via nasal cannula at 2 L/min): Current evidence does not support the routine use of maternal oxygen supplementation for Category III tracings without maternal hypoxemia. Furthermore, if oxygen is ordered, a non-rebreather mask at 10-15 L/min is the standard delivery device to achieve a high FiO2, not a nasal cannula at 2 L/min. This makes the option both a lower priority and technically incorrect.

Connecting to Broader Evidence and Risk Factors

The urgency of this scenario is further justified by the prevalence and impact of NRFHRS. Research indicates a significant prevalence of non-reassuring FHR patterns among laboring mothers, with associated factors including obstetric complications that compromise placental function . A study on late-onset fetal growth restriction, a condition inherently linked to placental insufficiency, found that specific clinical and ultrasonographic factors were associated with a high risk of cesarean delivery due to intrapartum fetal compromise . This client's presentation of recurrent late decelerations places her directly on this high-risk pathway, where timely recognition and escalation are the only actions that can prevent a catastrophic outcome. The nurse's immediate notification of the healthcare provider transforms the assessment data into a life-saving chain of events.References (research sources)

- [2]Non-reassuring fetal heart rate and associated factors among laboring mothers at southern public hospitals in Ethiopia: a poisson regression model.Research articleAsnake AB, Desalew A, Meseret F, Mezmur H. (2026) · DOI: 10.1038/s41598-026-35575-6

- [3]Magnitude, associated factors, and immediate outcomes of nonreassuring fetal heart rate status among laboring mothers in Ethiopia: a systematic review and meta-analysis.Meta-analysis/systematic reviewYilak G, Molla B, Tilahun BD, Abate BB, Kitaw TA, Kassie A, Getie A, Erega BB, Ayele M, Lake ES. (2026) · DOI: 10.1016/j.xagr.2026.100620

## 임상 시나리오

Clinical Guide: Managing Late Decelerations

Assessment & Recognition

- **Pattern:** Gradual decrease in FHR starting after contraction peak, returning to baseline post-contraction.

- **Significance:** Indicates uteroplacental insufficiency leading to fetal hypoxemia and metabolic acidosis.

- **Context:** High-risk finding in active labor (6 cm dilation, -1 station) requiring immediate escalation.

Priority Nursing Interventions

- **Notify Provider:** Immediate communication of findings, FHR tracing, and maternal status to obstetrician or midwife for urgent delivery decision.

- **Maternal Positioning:** Reposition to left lateral to maximize uterine blood flow and placental perfusion.

- **Oxygen Administration:** Apply 10 L/min via non-rebreather mask to increase maternal-fetal oxygen gradient.

- **IV Fluid Bolus:** Increase rate of isotonic fluids as ordered to improve maternal circulating volume.

- **Discontinue Oxytocin:** If infusing, stop immediately to reduce uterine activity and improve placental refill time.

Ongoing Monitoring

- Continuous electronic fetal monitoring to assess resolution of decelerations.

- Maternal vital signs every 5-15 minutes, including blood pressure and oxygen saturation.

- Prepare for potential emergency cesarean section if pattern persists or worsens.

## 핵심 개념

- **Late Decelerations** — A gradual decrease in fetal heart rate beginning after the peak of a contraction and returning to baseline after the contraction ends, indicating uteroplacental insufficiency.
- **Uteroplacental Insufficiency** — A condition where the placenta cannot deliver enough oxygen and nutrients to the fetus, often manifested by late decelerations during labor.
- **Station** — The relationship of the fetal presenting part to the maternal ischial spines, measured in centimeters; -1 indicates the head is 1 cm above the spines.

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