The perinatal nurse notes a rapid decrease in the fetal heart rate (FHR) that does not recover immediately following an amniotomy. What action should the nurse perform first?
A.
Administer oxygen at 100%.
B.
Assess the maternal temperature.
C.
Perform a vaginal examination.
D.
Recheck the FHR in 30 minutes.
ANS: C
The nurse needs to assess the fetal heart rate immediately before and after the artificial rupture of the membranes. Changes such as transient fetal tachycardia may occur and are common. However, other fetal heart rate patterns, such as bradycardia and variable decelerations, may be indicative of cord compression or prolapse. The nurse should perform a vaginal examination to assess for cord prolapse. Administering oxygen may or may not be needed. Maternal temperature is assessed every 2 hours after artificial rupture of membranes but is not related to this situation. The nurse should not wait 30 minutes prior to doing anything.
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