Question

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a non stress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? A.Have the client change position.

B.Give the client orange juice.
C.Establish IV access.
D.Elevate the client's legs

Answer 1

A.Have the client change position. To address a variable deceleration in the fetal heart rate during a non-stress test, the nurse should have the client change position to relieve pressure on the umbilical cord. Further actions may include establishing IV access or elevating the client's legs.

Step-by-step explanation:

Variable deceleration in the fetal heart rate (FHR) during a non-stress test can indicate umbilical cord compression, which can be dangerous to the fetus. To address this, the nurse should initially have the client change position to relieve the pressure on the umbilical cord and potentially improve FHR. This can be done by having the client shift from their current position to a different one, such as lying on their side.

If the variable deceleration persists or worsens after changing position, the nurse may need to take further actions such as establishing IV access to administer fluids or medication, or elevating the client's legs to improve blood flow. Giving the client orange juice would not be an appropriate action in this situation as it would not directly address the variable deceleration.