A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?
A.
Change the client’s position.
B.
Palpate the uterus to assess for tachysystole.
C.
Increase the client’s IV infusion rate.
D.
Administer oxygen at 10 L/min via a nonrebreather mask.
The Correct Answer and Explanation is:
The correct answer is A. Change the client’s position.
Explanation:
Late decelerations in fetal heart rate (FHR) are a type of deceleration that occurs after the peak of a contraction and return to baseline after the contraction has ended. These decelerations can be a sign of uteroplacental insufficiency, meaning that the fetus may not be getting enough oxygen due to decreased blood flow through the placenta.
Immediate Response to Late Decelerations:
- Change the Client’s Position: The first action the nurse should take is to change the client’s position. Moving the client to the left lateral position is often effective because it helps improve blood flow to the placenta and increases uterine perfusion. This position can relieve pressure on the umbilical cord and improve fetal oxygenation, potentially resolving the late decelerations.
- Palpate the Uterus: While assessing for tachysystole (excessive uterine activity) by palpating the uterus is important, it should follow the initial step of repositioning the client. Tachysystole can contribute to fetal distress, and addressing this might also help alleviate late decelerations. However, repositioning the client is the primary intervention.
- Increase IV Infusion Rate: Increasing the IV infusion rate can help improve maternal hydration and blood volume, which can also support placental perfusion. However, this is secondary to the immediate need to change the client’s position.
- Administer Oxygen: Administering oxygen at 10 L/min via a nonrebreather mask can be considered if repositioning and other initial interventions do not resolve the issue. Oxygen can help improve fetal oxygenation, but it is not the first-line action.
In summary, the priority intervention for late decelerations is to change the client’s position, specifically to the left lateral side. This intervention directly addresses potential uteroplacental insufficiency and can help restore normal FHR patterns. Following this, further assessment and interventions can be made as needed based on the client’s response.