Level: Foundational
Difficulty: Easy
Subtopic: Fetal monitoring
NCLEX: During labor, the fetal heart rate tracing shows late decelerations and minimal variability. What is the nurse’s…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
During labor, the fetal heart rate tracing shows late decelerations and minimal variability. What is the nurse's priority action?
Question
A. Notify the provider, reposition the client, apply oxygen per protocol, and continue fetal monitoring.
B. Turn off the monitor to reduce maternal anxiety.
C. Ambulate the client in the hallway without notifying anyone.
D. Document as reassuring and continue routine care.
B. Turn off the monitor to reduce maternal anxiety.
C. Ambulate the client in the hallway without notifying anyone.
D. Document as reassuring and continue routine care.
Rationale
Correct answer: A. Notify the provider, reposition the client, apply oxygen per protocol, and continue fetal monitoring.
Rationale: Late decelerations with minimal variability suggest uteroplacental insufficiency; immediate nursing actions and provider notification are required.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Late decelerations with minimal variability suggest uteroplacental insufficiency; immediate nursing actions and provider notification are required.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.