Health Promotion and Maintenance
80. A client, who is gravida 2, para 0 at 38 weeks' gestation, is having sharp decreases in fetal heart rate from a baseline of 130 bpm to 90 to 110 bpm during the contractions. Which action should a nurse take first?
. Reposition the monitor.
. Turn the client to her left side.
. Ask the client to ambulate.
. Prepare the client for delivery.
Test-Taking Tip
Envision the type of decelerations that occur during a contraction and think about the actions that would resolve the pattern of decelerations.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because this action will do nothing to resolve the decelerations of the fetal heart tones. This would be an appropriate action if there was an inconsistent or broken tracing. Answer 2 is correct because the first action the nurse should take is to turn the client to her left side, which may help resolve the variable decelerations. Answer 3 is incorrect because asking the client to ambulate may make the variable decelerations worse, especially if the reason for the decelerations is cord compression. Answer 4 is incorrect because preparing the client for delivery is not the first action the nurse should take, since it will not resolve the decelerations.