# A nurse is caring for a laboring client at 40 weeks gestation. The fetal heart rate monitor shows late decelerations with each contraction, and the baseline fetal heart rate has dropped from 140 bpm to 110 bpm over the past 30 minutes. The client is currently in the supine position. What is the nurse's priority intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543070 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is caring for a laboring client at 40 weeks gestation. The fetal heart rate monitor shows late decelerations with each contraction, and the baseline fetal heart rate has dropped from 140 bpm to 110 bpm over the past 30 minutes. The client is currently in the supine position. What is the nurse's priority intervention? ## 보기 1. Administer oxygen at 8-10 L/min via face mask 2. Increase the rate of intravenous fluid infusion 3. Prepare for immediate cesarean delivery 4. Reposition the client to left lateral position **✔ 정답** **정답: 4** ## 해설 Late decelerations with a dropping baseline indicate fetal hypoxia due to uteroplacental insufficiency. Repositioning to left lateral is the priority to relieve aortocaval compression and improve placental perfusion. Oxygen and fluids are secondary, and cesarean is reserved if conservative measures fail. ## 심화 해설 Clinical Scenario Analysis The fetal heart rate (FHR) monitor reveals two critical findings: late decelerations with each contraction and a declining baseline FHR from 140 bpm to 110 bpm over 30 minutes. Late decelerations are a hallmark of uteroplacental insufficiency (UPI), where the fetus experiences transient hypoxemia during uterine contractions because placental perfusion is compromised . The gradual drop in baseline FHR suggests the fetus is depleting its glycogen reserves and transitioning from a compensatory sympathetic response to a decompensatory state, risking metabolic acidosis . This pattern is a classic, non-reassuring fetal heart rate status (NRFHRS), which is strongly associated with fetal hypoxia and adverse perinatal outcomes . Prioritizing Nursing Interventions The nurse must apply the least invasive, most rapidly effective intervention first to correct the underlying physiological insult. The client is currently in the supine position. In this position, the gravid uterus compresses the maternal aorta and inferior vena cava, a condition known as supine hypotensive syndrome or aortocaval compression. This mechanical compression directly reduces maternal cardiac output and placental blood flow, which is the most immediate and reversible cause of the observed UPI and late decelerations . Therefore, the priority intervention is to alleviate this compression. Repositioning the client to the left lateral position displaces the uterus off the great vessels, immediately improving maternal venous return, cardiac output, and uteroplacental perfusion. This simple action often resolves the late decelerations and allows the fetal heart rate to recover without further intervention. The other options are important but are secondary or tertiary interventions to be performed if repositioning fails to resolve the pattern: - Administering oxygen (Option 1) increases the oxygen gradient for diffusion but will be ineffective if placental blood flow is mechanically obstructed. - Increasing intravenous fluids (Option 2) can expand maternal circulating volume and support cardiac output, but it does not directly remove the mechanical obstruction caused by the supine position. - Preparing for immediate cesarean delivery (Option 3) is the definitive treatment for persistent NRFHRS indicating fetal intolerance to labor, but it is not the first-line action before attempting intrauterine resuscitation measures . ## 임상 시나리오 Clinical Practice Guide **Scenario:** Laboring client with late decelerations and declining baseline fetal heart rate while in supine position. **Priority Intervention Rationale:** - Late decelerations with a dropping baseline indicate uteroplacental insufficiency (UPI) and fetal decompensation. The supine position causes aortocaval compression, directly reducing placental perfusion. Repositioning to the left lateral position is the most immediate, non-invasive, and physiologically corrective action. **Step-by-Step Intrauterine Resuscitation:** - **Reposition:** Turn the client to the left lateral position. If contraindicated, a right lateral or hands-and-knees position can be used. This displaces the uterus off the inferior vena cava and aorta. - **Oxygenate:** If the FHR pattern does not improve within 1-2 minutes, administer oxygen at 10 L/min via a non-rebreather face mask to maximize maternal-fetal oxygen gradient. - **Hydrate:** Increase the rate of the primary intravenous infusion (e.g., Lactated Ringer's or Normal Saline) to a bolus rate as ordered, typically 500-1000 mL, to expand intravascular volume and improve uteroplacental blood flow. - **Notify:** Immediately notify the obstetric provider of the findings, interventions, and fetal response. If the non-reassuring pattern persists after these measures, prepare for expedited operative delivery (vacuum, forceps, or cesarean). - **Discontinue Uterotonics:** If oxytocin is infusing, stop it immediately to reduce uterine activity and allow maximal placental reperfusion between contractions. **Ongoing Monitoring:** - Continuously monitor FHR and uterine activity for resolution of late decelerations and return of baseline variability. - Assess maternal vital signs, especially blood pressure, to rule out maternal hypotension as a contributing factor. - Document all interventions, maternal-fetal responses, and provider notifications in the medical record. ## 핵심 개념 - **Late decelerations** — Fetal heart rate decreases that begin after the peak of a contraction and return to baseline after the contraction ends, indicating uteroplacental insufficiency. - **Supine hypotensive syndrome** — A condition where the gravid uterus compresses the inferior vena cava and aorta when the mother lies flat on her back, reducing cardiac output and placental perfusion. - **Uteroplacental insufficiency (UPI)** — A condition where placental blood flow is inadequate to meet fetal oxygen and nutrient demands, often manifesting as late decelerations. - **Left lateral position** — A maternal position where the woman lies on her left side, which displaces the uterus off the major vessels to maximize cardiac output and placental blood flow. - **Non-reassuring fetal heart rate status (NRFHRS)** — Fetal heart rate patterns, such as late or variable decelerations, that are associated with fetal hypoxia and require prompt nursing intervention. ## 같은 주제 문제 - [A nurse is monitoring a laboring client when the fetal heart rate tracing shows late decel…](https://mymerci.kr/pages/nclex_q.php?qn_id=543066) - [A nurse is monitoring a 32-year-old primigravida at 41 weeks gestation when the fetal hear…](https://mymerci.kr/pages/nclex_q.php?qn_id=543067) - [A nurse is monitoring a laboring client when the fetal heart rate tracing shows late decel…](https://mymerci.kr/pages/nclex_q.php?qn_id=543068) - [A nurse is caring for a laboring client at 38 weeks gestation. The fetal heart rate monito…](https://mymerci.kr/pages/nclex_q.php?qn_id=543069) - [A nurse is monitoring a laboring client when the fetal heart rate monitor shows late decel…](https://mymerci.kr/pages/nclex_q.php?qn_id=543071) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._