The nurse observes early decelerations on the fetal monitor. What action should the nurse take?
a. Document the observations. c. Change the woman's position.
b. Administer oxygen via mask. d. Check the maternal vital signs.
A
Early decelerations during the second stage of labor and in the presence of adequate descent of the presenting part are manifestations of normal response by the fetus to pressure on the head caused by uterine contractions. The nurse's responsibility at this time is to document and observe. Changing the woman's position and vital signs or administering oxygen are not necessary. These are normal responses by the fetus to pressure on the head caused by uterine contractions during early decelerations.
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