A nurse is providing care for a client who is in labor.
The nurse notes variable decelerations on the fetal heart rate monitor.
What could be the cause?

Choice A rationale:

While some of the client's findings are consistent with normal labor progression, the decelerations in the fetal heart rate (FHR) are concerning and indicate a potential problem. Normal labor progression would not typically involve FHR decelerations.

Choice B rationale:

Monitoring contractions and fetal heart rate: This is crucial to assess the client's labor progress and fetal well-being. The frequency, duration, and intensity of contractions, as well as the baseline FHR, variability, and presence of any decelerations, should be closely monitored. These parameters provide essential information about the adequacy of uterine contractions, fetal oxygenation, and potential need for interventions.

Choice C rationale:

Ensuring the client is comfortable and hydrated: Comfort measures can help the client cope with labor pain and anxiety, which can indirectly improve fetal oxygenation by reducing stress hormones. Hydration is essential for maintaining adequate blood flow to the placenta and fetus, supporting fetal well-being.

Choice D rationale:

While monitoring pain level and fluid intake is important, they are not the most immediate priorities in this situation. The priority is to address the potential fetal distress indicated by the FHR decelerations and ensure adequate uterine contractions and fetal oxygenation.

Additional notes:

The nurse should also notify the healthcare provider of the FHR decelerations and any other concerning findings.

Further interventions, such as changing the client's position, administering oxygen, or discontinuing the oxytocin infusion, may be necessary depending on the assessment findings and provider's orders.

Choice A is incorrect. Preterm labor is defined as uterine contractions that occur before 37 weeks of gestation. The

client in this case is at 38 weeks of gestation, which is considered term gestation. Therefore, preterm labor is not the

most likely condition the client is experiencing.

Rationale for Choice B

Choice B is partially correct. While bed rest may be recommended for some clients experiencing certain conditions

during pregnancy, it is not the most appropriate intervention for all clients at 38 weeks of gestation. Additionally,

administering medication without knowing the specific condition the client is experiencing is not safe or ethical.

Rationale for Choice C

Choice C is correct. Monitoring contraction frequency and fetal heart rate are two of the most important actions a

nurse can take to assess a client at 38 weeks of gestation. These parameters can provide valuable information about

the client's progress and help to identify any potential problems.

Explanation:

At 38 weeks of gestation, the client is considered to be at term. This means that she is full-term and her baby is ready

to be born. However, even at term, there are a number of conditions that can occur that may require nursing

intervention.

One of the most common conditions that can occur at term is labor. Labor is the process by which the uterus contracts

and dilates to push the baby out of the birth canal. The nurse should monitor the client for signs and symptoms of

labor, such as:

Regular contractions that are becoming stronger and closer together

Bloody show (mucus mixed with blood)

Rupture of membranes (breaking of water)

If the nurse suspects that the client is in labor, she should notify the healthcare provider immediately.

Another condition that can occur at term is preeclampsia. Preeclampsia is a serious condition that can cause high

blood pressure, protein in the urine, and swelling in the face, hands, and feet. If the nurse suspects that the client has

preeclampsia, she should monitor the client's blood pressure, protein levels in the urine, and weight. She should also

notify the healthcare provider immediately.

In addition to monitoring for these specific conditions, the nurse should also perform a general assessment of the

client's health. This includes taking the client's vital signs, checking her abdomen for fetal movement, and listening to

the baby's heartbeat.

By monitoring the client for signs and symptoms of these conditions, the nurse can help to ensure a safe and healthy

delivery for both the mother and the baby.

Therefore, the two most important actions the nurse should take are:

Monitor the client for signs and symptoms of labor and preeclampsia.

Perform a general assessment of the client's health.

The two most important parameters the nurse should monitor are:

Contraction frequency and intensity

Fetal heart rate

By following these steps, the nurse can provide the best possible care for the client and her baby.