What is the most appropriate nursing action? A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip.
A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of Pitocin IV infusion
Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary.Option A: The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava.Option D: An intravenous Pitocin infusion is discontinued when a late deceleration is noted.