Question

The nurse who is caring for the laboring client notes a decline of fetal heart tones from 136 to 90 beats per minute after the acme of the contractions. Which action is most appropriate at this time? ? A. Monitor the client’s blood pressure ? B. Turn the client to her left side ? C. Assess the urinary output hourly ? D. Prepare the client for a cesarean section

Short answer

Answer: The most appropriate initial action is to turn the client to her left side. This intervention can help optimize blood flow to the uterus and the baby, potentially improving the fetal heart tones and allowing for further assessment of the situation.

Step-by-step solution

Option A: Monitor the client's blood pressure

While monitoring the client's blood pressure may provide useful information, it is not the most appropriate immediate action in response to a decline in fetal heart tones.

Option B: Turn the client to her left side

Turning the client to her left side can help optimize blood flow to the uterus and the baby, which may improve the fetal heart tones. This is a common nursing intervention for situations with non-reassuring fetal heart tones and should be considered as an appropriate initial response.

Option C: Assess the urinary output hourly

Assessing the client's urinary output hourly may provide useful information about her overall fluid balance, but it is not a direct response to the declining fetal heart tones and not the most appropriate immediate action in this situation.

Option D: Prepare the client for a cesarean section

While a cesarean section may be necessary in some cases with non-reassuring fetal heart tones, it is important to first attempt less invasive interventions, such as turning the client to her left side, to see if the situation can be improved and avoid the potential risks and complications of a cesarean section.

Final Answer

The most appropriate action at this time is B. Turn the client to her left side. This intervention can help optimize blood flow to the uterus and the baby, potentially improving the fetal heart tones and allowing for further assessment of the situation.

Key concepts

Fetal Heart Rate Monitoring

Fetal heart rate monitoring is a crucial component of prenatal care during labor. It provides vital information about the baby's well-being and can indicate how well the fetus is coping with the labor process. A normal fetal heart rate typically ranges from 110 to 160 beats per minute (bpm). Fluctuations within this range are considered normal, but a sustained rate below or above can signal distress.

In cases where there's a significant drop in fetal heart rate, such as a decline from 136 to 90 bpm after the peak of a contraction (as noted in the exercise), immediate action is necessary. This finding is indicative of potential fetal hypoxia, where the baby may not be receiving enough oxygen. The cause of these non-reassuring heart tones could be due to several factors including uteroplacental insufficiency or cord compression.

Interventions should first aim to improve fetal oxygenation and might include changing the mother's position or administering oxygen. These steps can sometimes normalize the heart rate, negating the need for more invasive procedures. Continuous monitoring is essential to assess whether the fetus's condition is stabilizing or whether emergency delivery interventions, such as a cesarean section, are required.

Nursing Interventions During Labor

During labor, nurses play a key role in monitoring both the mother and the fetus. When non-reassuring heart tones are detected, quick and effective nursing interventions are crucial to mitigate any potential risks.

One of the first interventions is to turn the mother to her left side. This position is known to improve uterine blood flow and increase placental perfusion, thereby potentially enhancing fetal oxygen supply. Other initial steps may include:

• Administering oxygen to the mother to increase fetal oxygenation.
• Hydration, often with intravenous fluids, to improve blood volume and circulation.
• Discontinuing any labor-inducing medications, as these can exacerbate conditions leading to fetal distress.

Nurses also play a pivotal role in communicating with the healthcare team and preparing for potential interventions, which can range from further fetal monitoring to an urgent cesarean section if the situation doesn't improve.

Furthermore, advocating for the emotional well-being of the mother during this stressful time is another vital aspect of nursing care. Keeping the mother informed and supported throughout the process can significantly impact the labor experience.

Cesarean Section Preparation

Preparation for a cesarean section is a vital step when non-reassuring fetal heart tones do not improve with initial measures. As part of the team, nurses must act promptly to organize the operating room, ensure that necessary equipment and personnel are available, and manage the preoperative care of the mother.

Key preparatory steps include:

• Obtaining informed consent for the procedure after explaining the risks and benefits.
• Administering preoperative medications, if required.
• Ensuring the mother has an intravenous line in place for fluid and medication administration.
• Applying fetal heart rate monitoring up until the time of surgery.
• Positioning, prepping, and draping the mother in the operating room.

Moreover, cesarean section preparation involves emotional support and education for the parents-to-be. Clarifying what to expect during and after the surgery helps reduce anxiety and establishes trust in the medical team. Should a cesarean become necessary, the goal is always to ensure the safest outcome for both mother and baby.