What action should the nurse take?

Posted by: Pdfprep Category: NCLEX-RN Tags: , ,

When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability.

What action should the nurse take?
A . Continue monitoring because this is a normal occurrence.
B . Turn client on right side.
C . Decrease IV fluids.
D . Report to physician or midwife.

Answer: D


(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery.

(B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side.

(C) IV fluids should be increased, not decreased.

(D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.

Leave a Reply

Your email address will not be published.