The nurse is caring for a client in labor experiencing early decelerations. Which of the following actions should the nurse take?
The nurse is caring for a client in labor experiencing early decelerations. Which of the following actions should the nurse take?
A. Reposition the client on her side
[43%]
B. Document the findings
[44%]
C. Discontinue oxytocin infusion
[12%]
D. Prepare for an amnioinfusion
[1%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Labor/Delivery
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
Choice B is correct. Early decelerations are gradual decreases and return to baseline in fetal heart rate that typically coincides with contractions. They are usually benign and associated with head compression during contractions. No specific interventions are needed for early decelerations because they are considered a normal response to the pressure on the fetal head.
Choice A is incorrect. Repositioning the client is a common intervention for variable or late decelerations, which may be associated with cord compression or uteroplacental insufficiency. However, early decelerations do not typically require repositioning.
Choice C is incorrect. Discontinuing oxytocin infusion may be appropriate if there are concerns about uterine hyperstimulation or fetal distress. However, early decelerations are not generally associated with oxytocin infusion-related issues.
Choice D is incorrect. Amnioinfusion, which involves infusing sterile fluid into the amniotic cavity, is typically used to address variable decelerations associated with oligohydramnios. It is not a standard intervention for early decelerations.
Related Videos
3 Key Topics
Decelerations
29.1 Fetal Monitoring Basics
Additional Info
✓ Early decelerations are not associated with fetal compromise and do not require intervention.
✓ Early decelerations occur during contractions as the fetal head is pressed against the client's pelvis or cervix.
✓ While specific interventions may not be necessary for early decelerations, the nurse should be prepared to implement measures in case the fetal heart rate pattern changes or if other complications arise.
