Question

During auscultation of FHR during labor, nurse assesses a rate of 59 beats/min. Which actions does nurse take *first*?

A. turns client on right side, opens IV line, and calls health care provider
B. turns client on left side, administers oxygen by nasal cannula, and assures IV access
C. places client in semi-Fowler's position, provides ice, and calls health care provider
D. places client in Trendelenburg position, administers oxygen, and forces fluids

Answer 1

The nurse's first actions in response to a fetal heart rate (FHR) of 59 beats per minute during labor should be to turn the client on their left side, administer oxygen via a nasal cannula, and ensure IV access.

Step-by-step explanation:

The nurse assesses a fetal heart rate (FHR) of 59 beats per minute during auscultation of a laboring client. A FHR below the normal range of 110-160 beats per minute is considered bradycardia. Bradycardia can be caused by various factors, such as fetal distress, umbilical cord compression, placental insufficiency, or maternal hypotension. In response to this finding, the nurse should take immediate actions to address the potential cause of bradycardia and promote fetal well-being.

In this scenario, the nurse should first turn the client on their left side to relieve any potential compression on the inferior vena cava, which can improve blood flow to the fetus. This position change can help enhance fetal oxygenation and improve the FHR. The nurse should then administer oxygen to the client via a nasal cannula to increase the oxygen supply to the fetus and mitigate any potential hypoxia. Finally, ensuring IV access is important to maintain hydration and provide any necessary medications or interventions if the situation warrants.

In summary, the nurse's first actions should be to turn the client on their left side, administer oxygen by nasal cannula, and ensure IV access to address the bradycardia in FHR during labor.