The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip
Based on this finding, the nurse pre-pares for which most appropriate nursing actions? 1. Placing the mother in a supine position
2. Administering oxygen via face mask
3. Increasing the rate of the intravenous (IV) oxytocin infusion
4. Documenting the findings and continuing to monitor the fetal patterns
2
Rationale: Late decelerations are caused by uteroplacental insufficiency as the result of de-creased blood flow and oxygen to the fetus during the uterine contractions. This causes hypox-emia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late de-celeration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. "Documenting the findings and continuing to monitor the fetal patterns" would delay necessary treatment.
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