The nurse is evaluating the fetal monitor tracing of the patient who is in active labor.

Suddenly, the nurse sees the FHR drop from its baseline of 125 down to 80. The nurse repositions the mother, provides oxygen, increases intravenous fluids, and performs a vaginal exam.

The cervix has not changed.

Two minutes have passed, and the fetal heart rate remains in the 70s.

What additional nursing measures should the nurse take?

Choice A rationale
Erythromycin ophthalmic ointment does not prevent the infant's eyelids from sticking together; it is not its primary purpose and does not aid in vision enhancement.
Choice B rationale
Erythromycin ophthalmic ointment is used to prevent gonorrheal infection acquired during birth, protecting the infant’s eyes from potential infection that can cause blindness.
Choice C rationale
Erythromycin does not prevent exudate from invading the tear ducts, nor does it lead to dry eyes. Its primary function is antimicrobial.
Choice D rationale
Erythromycin ophthalmic ointment is not specific to Staphylococcus and does not directly destroy infectious exudate. It prevents infections like gonorrhea.

Choice A rationale
Notifying the provider is important but does not address the immediate need to assess the patient's progress and readiness for delivery. A direct intervention is required to determine the next steps.
Choice B rationale
Performing a sterile vaginal exam allows the nurse to assess cervical dilation and effacement, fetal station, and presentation, which are crucial to determine if the patient is ready to push and proceed with delivery.
Choice C rationale
Supportive words and care are essential for patient comfort, but they do not provide the necessary assessment to determine the patient's progress in labor or readiness for pushing.
Choice D rationale
Monitoring the fetal heart rate tracing is important for assessing fetal well-being but does not specifically address the patient's readiness to push or her labor progress.