Health Promotion and Maintenance
86. A client, who is gravida 4, para 3, is 4 cm dilated, 80% effaced, and a +1 station. Assessment of the fetal monitor tracing reveals baseline 140 bpm, moderate variability, and accelerations and variable decelerations to 100 bpm. Which action should a nurse take first?
Test-Taking Tip
Assess the fetal monitor strip in the same way each time: What is the baseline and is it normal? What is the variability and is it normal? Are there accelerations? Are there decelerations and what types of decelerations are present? What interventions are appropriate for each type of deceleration?
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Health Promotion and Maintenance
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Answer 1 is incorrect because the nurse should try to resolve the variable decelerations before notifying the physician. Answer 2 is incorrect because, although giving a 500-mL bolus IV is part of the intervention to resolve variable decelerations, repositioning the client is the first action the nurse should take. Answer 3 is correct because repositioning the client will help to alleviate the variable decelerations. This should be the first action of the nurse. Answer 4 is incorrect because readjusting the monitor does nothing to resolve the variable decelerations.
