Physiological Integrity Q 26
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
A. Notify her doctor
B. Start an IV
C. Reposition the client
D. Readjust the monitor
Correct Answer: C. Reposition the client
The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Initial management of recurrent variable decelerations should have a target of relieving potential cord compression. Maternal repositioning is a reasonable first maneuver. Variable decelerations can be seen resulting from fetal movement if the fetus is premature.
Option A: Notifying the physician might be necessary but not before turning the client to her side. Recurrent variable decelerations during labor require evaluation. Initial evaluation includes characterization of the decelerations themselves, including their frequency, depth, and duration. It is also important to assess the uterine contraction pattern and the other fetal heart tracing characteristics.
Option B: Starting an IV is not necessary at this time. In specific clinical scenarios that may result in concerning variable decelerations, management should be directed by the etiology of those decelerations. If a patient is having uterine tachysystole, reducing the number of contractions by decreasing oxytocin or administration of a beta-agonist may be appropriate.
Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied incorrectly. Electronic fetal monitoring is utilized in approximately 85% of live births in the United States, making it the most common procedure in obstetrics. This frequency represents an increase since 1980 when its use was about only 45% of women in labor. Intermittent, variable decelerations, defined as decelerations occurring with less than half of contractions, are the most common fetal heart rate abnormality that takes place in labor.