Question

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measure should you take? A) Call for help B) Insert a Foley catheter C) Start oxytocin (Pitocin) D) Notify the primary health care provider immediately

Answer 1

D

Step-by-step explanation:

To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. Pitocin may place additional stress on the fetus.