65. A client, who is gravida 5, para 2 at 41 weeks' gestation, is in active labor. She is having contractions every 2 to 3 minutes and they are moderate in intensity. Her cervix is 6 cm dilated, 90% effaced, and a -1 station. The fetal heart rate (FHR) baseline is 120 with moderate long-term variability, no accelerations in the past 30 minutes, and three late decelerations noted within the last 15 minutes. Which nursing action is most appropriate?
. Encourage the client to ambulate.
. Position the client on her back so the monitor strip is more accurate.
. Turn the client to her left side.
. Prepare for an emergency cesarean section.
Test-Taking Tip
Remember the physiology of different types of decelerations and the interventions that are needed to relieve them. Late decelerations require immediate intervention to prevent compromise of fetal oxygen perfusion.
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
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Answer 1 is incorrect because ambulation is encouraged in the presence of a reassuring fetal monitor tracing. Late decelerations are caused by decreased uteroplacental perfusion and are a non-reassuring pattern. Answer 2 is incorrect because positioning the client in a supine position causes compression of the major vessels of the pelvis. This position will compromise placental perfusion and contribute to fetal distress. Answer 3 is correct because late decelerations are caused by decreased uteroplacental perfusion. Turning a woman on her side increases placental perfusion and subsequent fetal oxygenation. This position change may end the late decelerations. Answer 4 is incorrect because the fetus still has oxygen reserve as evidenced by moderate baseline variability. An emergency operative delivery is not yet required.