Question

The client is admitted to the labor unit following spontaneous rupture of membranes. Upon assessment of the client’s condition, the nurse notes the fetal heart tones are 160–170 beats per minutes. There is a dark green vaginal discharge, and the client’s cervix is 50% effaced. The nurse’s initial action should be to do which of the following? ? A. Document the finding ? B. Apply oxygen via mask ? C. Insert a Foley catheter ? D. Begin an IV of normal saline

Short answer

Answer: B. Apply oxygen via mask

Step-by-step solution

Analyze the given information

In this scenario, the nurse should consider the following information: 1. Fetal heart tones are 160-170 beats per minute (bpm): This is important because a normal fetal heart rate range is between 110-160 bpm, so this may indicate fetal distress. 2. Dark green vaginal discharge: This is a sign of meconium, which might indicate fetal distress. 3. Cervix is 50% effaced: This shows the progress of labor. Based on this information, it is crucial to address the potential fetal distress indicated by the high fetal heart rate and meconium presence.

Evaluate the given options

Now we can evaluate each of the four initial actions as follows: A. Document the finding: The nurse should always document findings, but prioritizing documentation is not the most appropriate initial action in this case. Immediate intervention might be necessary to address the potential fetal distress. B. Apply oxygen via mask: Administering oxygen to the client can help improve fetal oxygenation if there is fetal distress. This is a reasonable action to consider in response to the high fetal heart rate and meconium presence. C. Insert a Foley catheter: A Foley catheter is used to drain urine from the bladder during labor to assist in cervical dilation and improve the descent of the fetus. However, it is not directly related to addressing potential fetal distress. D. Begin an IV of normal saline: While beginning an IV of normal saline might be necessary during labor, it is not the most appropriate initial action to take in this specific scenario focusing on the potential fetal distress.

Choose the most appropriate initial action

After evaluating the options, we can rule out A, C, and D as they do not directly address fetal distress. The most appropriate initial action in this case is: B. Apply oxygen via mask This will help improve fetal oxygenation and address the potential fetal distress indicated by the high fetal heart rate and the presence of meconium in the vaginal discharge.

Key concepts

Fetal Distress Management

When it comes to managing fetal distress during labor, it's essential for nurses and healthcare providers to act swiftly and effectively. Fetal distress refers to signs before or during childbirth indicating that the fetus is not well. This can be due to a lack of oxygen (hypoxia) or other factors. Recognizing the signs of fetal distress, such as a high fetal heart rate (above 160 bpm) and meconium-stained amniotic fluid, is key to prompt management.

Immediate interventions may include repositioning the mother to improve blood flow, administering oxygen via mask to increase the oxygen available to the fetus, and potentially preparing for an urgent delivery, whether by instrumental delivery or cesarean section, if the distress is not resolved quickly. Continuous fetal heart rate monitoring is vital to assess the effectiveness of the actions taken and determine the next steps. In the scenario presented, applying oxygen via mask is a priority intervention aimed at improving the fetal condition.

Labor and Delivery Nursing Care

Nurses in labor and delivery play a pivotal role in ensuring both maternal and fetal well-being. Their responsibilities are multidimensional, involving clinical expertise, supportive care, and critical decision-making. When providing care, nurses must keep several factors in mind, such as the stage and progress of labor, the mother's comfort and pain management needs, and the ongoing assessment of fetal well-being.

Key nursing actions include monitoring labor progress through cervical effacement and dilation, providing pain relief measures, assisting with positioning, and preparing for potential interventions or emergency situations. Quality nursing care also encompasses emotional support and clear communication with the laboring mother and her family. Additionally, preparing for timely interventions, such as the initiation of IV fluids or catheter placement, is critical, but these should be weighed against the immediate needs related to maternal or fetal distress.

Fetal Heart Rate Monitoring

Continuous fetal heart rate (FHR) monitoring is a central component of fetal surveillance during labor. It provides critical information about the fetal condition and aids in early detection of potential distress. FHR is typically monitored through electronic fetal monitoring, which can be external or internal. The normal range for a fetal heart rate is between 110-160 beats per minute; deviations from this range may indicate problems such as hypoxia or infection.

When analyzing the FHR, healthcare providers look for patterns such as accelerations and decelerations, which can give clues about fetal well-being. For instance, late decelerations may suggest uteroplacental insufficiency, while variable decelerations might indicate umbilical cord compression. FHR monitoring allows for timely interventions, which in the provided exercise, emphasizes the need for applying oxygen to manage the indicated fetal distress. Understanding FHR patterns and intervening as necessary are vital skills in labor and delivery care.