You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR)
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 measures should you take?
The best answer to the question: What additional nursing measures should you take, would be: Inform the Primary Care Provider, the physician of the patient, before anything else.
Explanation:
The reason for this being the most important step at this stage is that the nurse has already taken whatever measures were necessary to help the baby, who is evidently suffering at this point. By administering oxygen, repositioning the mother, administering further fluids, and performing the vaginal exam, the nurse knows now that the PCP needs to be informed to determine further actions, especially if a cesarean section will be needed to prevent further stress of the baby. Any other actions before this would only further the distress on the baby and complicate labor even further.
1st: Point at someone and tell them to call 911 2nd: Point at a worker near you and if there isn't one point to a person and tell them to go see if anyone near has a defibrillator 3rd: Start CPR with 30 chest compressions before giving two rescue breaths
