You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80
You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?
a. Scream for help.
b. Insert a Foley catheter.
c. Start Pitocin.
d. Notify the care provider immediately.
ANS: D
To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. Pitocin may place additional stress on the fetus.
You might also like to view...
The nurse advises a patient who is taking cholinergic drugs to avoid standing quickly and to rise to an upright position slowly. Which complication associated with the drug is the nurse trying to prevent?
A. Dyspnea B. Muscle cramps C. Postural hypotension D. Nausea and vomiting
A period of continuous or intermittent unconsciousness in which physical movement is decreased is
A. comfort. B. rest. C. sleep. D. pain.
When teaching a client how to take his or her own pulse, a nurse should instruct the client to:
A. Press hard over the pulse site B. Assess the pulse before taking medications C. Massage the neck to get the carotid pulse D. Count the rate for 15 seconds and multiply by 4
The ability of a cardiac muscle to respond to an electrical stimulus is called _______________________
Fill in the blank(s) with correct word