When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply

Turn the patient to her side.

Provide 2-3 liters of oxygen via mask

Notify the health care provider.

Stop the oxytocin

Answer and Explanation

Correct Answer : A,B,C,D

A. Turning the patient to her side can improve placental blood flow and alleviate pressure on the umbilical cord, which is often the cause of late decelerations.

B. Providing oxygen can help improve oxygenation to the fetus, especially if the decelerations are due to uteroplacental insufficiency.

C. Notifying the healthcare provider is essential to address the situation promptly and determine whether further interventions or a change in labor management is necessary.

D. Stopping oxytocin can reduce uterine contractions and prevent further stress on the fetus, especially if the late decelerations are linked to uterine hyperstimulation.

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Correct Answer is C

Explanation

A. Administering oxygen via mask is indicated when there is concern for fetal hypoxia, such as late decelerations or variable decelerations.

B. Repositioning the woman may be appropriate if fetal heart rate patterns are concerning, but in this case, the decelerations are likely to be normal variable decelerations.

C. This is a pattern of early decelerations, which is typically benign and reflects fetal head compression. The appropriate action is to document and continue monitoring.

D. Applying a fetal scalp electrode is not indicated unless there is difficulty obtaining an accurate fetal heart rate on external monitoring.

A. If she has had prenatal care. B. Membrane status and her EDD/EDC. C. Time of last food intake and fasting blood sugar. D. Pain level and birth plan.

Correct Answer is B

Explanation

A. Prenatal care history is important but not as urgent as membrane status and estimated delivery date.

B. Membrane status and estimated delivery date are critical for assessing the stage of labor and planning care.

C. Fasting blood sugar is relevant in diabetic patients but not an immediate priority.

D. Pain level and birth plan are important but secondary to assessing labor progress.

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When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply

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Naxlex Comprehensive Predictor Exams

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