Author Question: Which deceleration of the fetal heart rate would not require the nurse to change the maternal ... (Read 58 times)

tth · **on:** Jun 28, 2018

Which deceleration of the fetal heart rate would not require the nurse to change the maternal position?

a. Early decelerations
b. Late decelerations
c. Variable decelerations
d. It is always a good idea to change the woman's position.

Question 2

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC).

The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:
a. Notify the woman's primary health care provider immediately.
b. Prepare to administer an oxytocic to stimulate uterine activity.
c. Document the findings because they reflect the expected contraction pattern for the active phase of labor.
d. Prepare the woman for the onset of the second stage of labor.

FergA · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
Early decelerations (and accelerations) generally do not need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral); variable decelerations also require a maternal position change (side to side). Although changing positions throughout labor is recommended, it is not required in response to early decelerations.

Answer to Question 2

ANS: C
The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse would document these findings in the client's medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary care provider at this time.
Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.