The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first?
1. Alert the physician/CNM of the fetal status.
2. Administer oxygen to the patient at 4 liters per minute via nasal cannula.
3. Decrease the rate of infusion of intravenous fluids.
4. Facilitate a maternal left lateral position.
Correct Answer: 4
Rationale 1: While the attending physician or CNM should be notified, the priority nursing interventions target alleviation of the causative factors by way of direct patient care. Initially, the mother should be placed in the left lateral position.
Rationale 2: Initially, the mother should be placed in the left lateral position to promote maximal uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 liters per minute via facemask.
Rationale 3: Nursing interventions indicated in the treatment of late decelerations include increasing the rate of administration of intravenous fluids.
Rationale 4: In the treatment of late decelerations, the mother should immediately be placed in the left lateral position in order to promote maximal uteroplacental blood flow.
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