When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
A.
Continue monitoring because this is a normal occurrence.
Suggested Answer:D🗳️
(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
Answer is D
Late decelerations can be a sign that the baby isn’t getting enough oxygen. Late decelerations that occur along with a fast heart rate (tachycardia) and very little variability can mean that the contractions may be harming the baby by depriving them of oxygen.
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