A nurse assessing a fetal heart monitor notes minimal baseline variability not associated with a fetal sleep cycle. There is no change after fetal scalp stimulation. What action by the nurse is most important?
A.
Administer a bolus of IV fluids.
B.
Administer oxygen at 8-10 L/min per mask.
C.
Offer support to the patient and her partner.
D.
Prepare to assist with internal fetal monitoring.
ANS: B
All options are correct actions for the nurse to take in this situation. However, actions should be prioritized using the A (airway), B (breathing), C (circulation) method. The breathing action (administering oxygen) should occur prior to the circulation action (IV fluids) in the absence of any other data.
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