Maternity Nursing Q 205
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
A. Change the client’s position.
B. Prepare for an emergency cesarean section.
C. Check for placenta previa.
D. Administer oxygen.
Correct Answer: A. Change the client’s position.
Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client’s position from supine to side-lying may immediately correct the problem.
Option B: An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful.
Option C: Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent. It does not include placenta previa.
Option D: Administering oxygen may be helpful, but the priority is to change the woman’s position and relieve cord compression. The fetus already has a surplus of oxygen due to high basal blood flow to its organs and vascular shunts.