The nurse will implement the following interventions based on the fetal heart rate.A nurse is caring for a 35-year-old female client who is at 37 weeks of gestation in the antepartum unit. Exhibits The nurse will implement the following interventions based on the fetal heart rate. (Select All That Apply.) (Select All That Apply.)
Explanation & Rationale
Choice A rationale: Assist the patient onto her left side Positioning the patient on her left side helps improve uteroplacental blood flow by reducing compression of the inferior vena cava. This can enhance oxygen delivery to the fetus and mitigate late decelerations. Choice B rationale: Assist with a vaginal exam for cord prolapse Cord prolapse occurs when the umbilical cord slips ahead of the presenting fetal part, leading to variable decelerations rather than late decelerations. Since late decelerations indicate placental insufficiency rather than cord prolapse, this intervention is not necessary. Choice C rationale: Discontinue the oxytocin infusion Oxytocin is used to stimulate contractions, but excessive contractions can lead to uteroplacental insufficiency, causing late decelerations. Discontinuing oxytocin reduces uterine stress and improves fetal oxygenation. Choice D rationale: Administer oxygen at 10 L/min via nonrebreather face mask Providing high-flow oxygen increases maternal oxygenation, which in turn enhances fetal oxygen delivery. This intervention is a standard response to late decelerations. Choice E rationale: Notify the health care provider Late decelerations suggest fetal distress due to uteroplacental insufficiency, requiring urgent evaluation and possible escalation of care, such as intrauterine resuscitation or expedited delivery. Choice F rationale: Stop the magnesium sulfate Magnesium sulfate is administered for seizure prevention in preeclampsia and does not directly contribute to late decelerations. Therefore, stopping magnesium sulfate is not necessary in this situation.