Question

During the 2nd stage of labor, the nurse notes a pattern of FHR decelerations between 80 and 100 from a baseline of 160. The decelerations are unrelated to the contractions, & moderate long-term baseline FHR variability is present. Place the interventions for these findings in order, starting with the highest priority first.

A) Administer oxygen, Change the patient's position, Prepare for emergency cesarean section
B) Change the patient's position, Administer oxygen, Prepare for emergency cesarean section
C) Prepare for emergency cesarean section, Administer oxygen, Change the patient's position
D) Administer oxygen, Prepare for emergency cesarean section, Change the patient's position

Answer 1

The highest priority intervention for FHR decelerations during the 2nd stage of labor is to change the patient's position, followed by administering oxygen, and preparing for an emergency cesarean section if necessary.

Step-by-step explanation:

During the 2nd stage of labor, when the nurse notes a pattern of FHR decelerations between 80 and 100 from a baseline of 160, and the decelerations are unrelated to contractions with moderate long-term baseline FHR variability present, the immediate interventions should be aimed at relieving potential fetal distress and optimizing fetal oxygenation.

1. Change the patient's position: This can relieve pressure on the umbilical cord or improve placental blood flow, possibly resolving the decelerations.
2. Administer oxygen: Supplemental oxygen can increase maternal blood oxygen saturation, potentially improving fetal oxygenation.
3. Prepare for emergency cesarean section: If the decelerations do not resolve and the fetus shows signs of distress, an emergency cesarean section may be necessary to prevent harm.