The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action would be which of the following?
1. Turn the client on her back, and administer oxygen by nasal cannula at 2 to 4 L/min.
2. Turn the client on her side, and administer oxygen by face mask at 8 to 10 L/min.
3. Turn the client on her back, and administer oxygen by face mask at 8 to 10 L/min.
4. Turn the client on her side, and administer oxygen by nasal cannula at 2 to 4 L/min.
2
Rationale: If a fetal heart rate begins to slow or a loss of variability is observed, this could indi-cate fetal distress. To facilitate oxygen to the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the mother by face mask.
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