Question

A nurse is caring for a client who is at 38 weeks of gestation and is in labor. The nurse notes late decelerations on the fetal monitor. (Order the steps of the process):

A. Increase the client's maintenance IV solution.
B. Administer oxygen via face mask at 8 L/min.
C. Reposition the client on her side.
D. Palpate the uterus to assess for tachysystole.

Answer 1

The correct order of steps to take when late decelerations are noted on the fetal monitor during labor is to reposition the client on her side, administer oxygen via face mask, increase the client's maintenance IV solution, and palpate the uterus to assess for tachysystole.

Step-by-step explanation:

The correct order of steps to take when late decelerations are noted on the fetal monitor during labor is as follows:

1. Reposition the client on her side. Repositioning the client can help improve blood flow to the fetus and relieve pressure on the umbilical cord, which may be causing the late decelerations.
2. Administer oxygen via face mask at 8 L/min. Providing oxygen can increase the oxygen supply to the fetus and help improve fetal heart rate patterns.
3. Increase the client's maintenance IV solution. Increasing the IV fluid can help improve fetal perfusion and hydration.
4. Palpate the uterus to assess for tachysystole. Tachysystole, which is defined as more than five contractions in 10 minutes, can contribute to inadequate uteroplacental circulation and lead to late decelerations.