The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best?
1. Determine the color of the leaking amniotic fluid.
2. Apply oxygen to the client at 2 L per nasal cannula.
3. Notify the operating room of the need for a cesarean birth.
4. Assist the client to change from the Fowler position to the left lateral position.
4
Explanation:
1. The fetus is exhibiting variable decelerations; there is no indication that the amniotic fluid is meconium-stained or bloody.
2. Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are preferable.
3. There is no indication that a cesarean delivery is needed. The fetus is exhibiting variable decelerations.
4. The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the client might get the fetus off the cord and eliminate the variable decelerations.
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