Maternity Nursing: Intrapartum Q 43

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Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to:

  

     A. Change the woman’s position

     B. Stop the Pitocin

     C. Elevate the woman’s legs

     D. Administer oxygen via a tight mask at 8 to 10 liters/minute

    

    

Correct Answer: B. Stop the Pitocin

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Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocin which stimulates the uterus to contract.

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Option A: The woman is already in an appropriate position for uteroplacental perfusion. A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended

Option C: Elevation of her legs would be appropriate if hypotension were present. Regardless of the depth of the deceleration, all late decelerations are considered potentially ominous. A pattern of persistent late decelerations is nonreassuring, and further evaluation of the fetal pH is indicated.

Option D: Oxygen is appropriate but not the immediate action. The occurrence of a late or worsening variable deceleration pattern in the presence of normal variability generally means that the fetal stress is either of a mild degree or of recent origin; however, this pattern is considered nonreassuring.

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