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    Rn Hesi Pediatric And Women Health Proctored Exam

    The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?

    Explanation & Rationale

    A. Turn off the oxytocin infusion: Stopping oxytocin may be necessary if uterine hyperstimulation is present, but the first response to variable decelerations is usually a position change to relieve cord compression. B. Assess cervical dilatation: Cervical assessment provides information on labor progress but does not immediately address fetal oxygenation or decelerations. C. Change the client's position: Variable decelerations are often caused by umbilical cord compression. Changing the mother’s position, such as to lateral or knee-chest, can relieve pressure on the cord and improve fetal oxygenation, making it the first intervention. D. Administer oxygen via facemask: Oxygen can support fetal oxygenation, but repositioning to relieve cord compression is the initial priority intervention before supplemental oxygen.

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