The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important?
1. Notify the surgical team of an impending cesarean.
2. Change the client's position from Fowler to left lateral.
3. Insert a Foley catheter with the assistance of another nurse.
4. Decrease the IV of lactated Ringer solution to 50 mL/hour.
2
Explanation:
1. The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions.
2. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow.
3. If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority.
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.
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