A primigravida is admitted to the birth setting in early labor. She is 3 cm dilated, ?2 station, with intact membranes and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations
The initial response from the nurse would be to: 1. Perform a vaginal exam.
2. Notify the physician.
3. Place the client in a left lateral position.
4. Administer oxygen at 2L per nasal cannula.
1
Rationale:
1. A drop in fetal heart rate accompanied by variable decelerations is consistent with a prolapsed cord, and a vaginal exam is the best way to confirm.
2. The vaginal exam should be done before notification of the physician.
3. Positioning will not relieve the decreased heart rate if the cord is compromised.
4. Oxygen will not relieve the decreased heart rate if the cord is compromised.
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