The laboring client has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100–105. Which nursing action is most important?

Question

1. Change the mother's position from Fowler's to left lateral.
2. Insert a Foley catheter with the assistance of another nurse.
3. Notify the surgical team of an impending cesarean.
4. Decrease the IV of lactated Ringer's solution to 50 ml/hour.

Answer 1

1
Rationale:
1. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow.
2. If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority.
3. The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions.
4. Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the client is hypotensive. Decreasing the IV rate will not improve fetal heart tones.