A client is in late active phase of labour. Suddenly she tells the nurse she feels weak and dizzy. The nurse notes the drop in maternal B.P. and late decelerations of fetal heart rate. The initial action the nurse should be to?

1. A

   Increase the I.V. drip rate and notify the provider

2. B

   Turn the client on side and administer oxygen

3. C

   Assess for cord prolapsed or vaginal bleeding

4. D

   Prepare for immediate delivery

Appeared in: GMCH Chandigarh - 2019

Explanation

• The client's symptoms of dizziness and hypotension, combined with late fetal heart rate (FHR) decelerations, are hallmark signs of uteroplacental insufficiency.
• This condition is often caused by supine hypotensive syndrome (aortocaval compression), where the weight of the gravid uterus compresses the inferior vena cava and aorta, reducing blood flow to the placenta.
• The immediate priority is to perform intrauterine resuscitation. The fastest and most effective initial action is to turn the client onto her side (preferably the left lateral position). This physically displaces the uterus off the major blood vessels, restoring maternal cardiac output and placental perfusion.
• Administering supplemental oxygen via a non-rebreather mask (8-10 L/min) is performed concurrently to maximize the oxygen available to the fetus.

Why Other Options Were Wrong

• Option A: Increasing the IV drip rate is a correct intervention for hypotension but is not the most immediate or primary action. Repositioning addresses the root cause of the problem (aortocaval compression) more quickly.
• Option C: This assessment is not the priority for the specific pattern of late decelerations. Late decelerations are caused by uteroplacental insufficiency, not typically by cord prolapse or bleeding.
• Option D: Preparing for immediate delivery is a later step in management. It is only considered if intrauterine resuscitation measures (repositioning, oxygen, IV fluids) fail to resolve the non-reassuring FHR pattern.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Management of Late Fetal Heart Rate Decelerations to guide bedside assessment, documentation, and the next nursing action.
• Prompt recognition and management of late decelerations are critical nursing responsibilities to prevent fetal hypoxia, acidosis, and potential neurological injury.
• This scenario highlights the importance of intrauterine resuscitation, a set of simple yet life-saving maneuvers that every labor and delivery nurse must be able to perform immediately.
• What if the FHR pattern showed severe variable decelerations instead of late decelerations? The initial action would shift. While repositioning is still beneficial, the nurse's first priority would be to perform a sterile vaginal exam to rule out a prolapsed umbilical cord.

How to Approach the Question

• First, identify the key clinical findings in the scenario: the client is in labor, feels dizzy, has low blood pressure, and the fetal monitor shows late decelerations.
• Recognize that this combination of maternal hypotension and late FHR decelerations points directly to a problem with uteroplacental perfusion.
• Recall the most common cause of this problem in a laboring woman: supine hypotensive syndrome (aortocaval compression).
• Think through the principles of intrauterine resuscitation. The goal is to improve blood flow and oxygen to the fetus.
• Prioritize the interventions. The fastest action that directly addresses the cause (compression of blood vessels) is changing the mother's position.
• Evaluate the options based on this priority. Turning the client to her side is the most immediate and effective initial action. Administering oxygen is also a primary step. The other options are secondary or indicated for different clinical situations.

Concept Tested & Keywords

• Concept Tested: Management of Late Fetal Heart Rate Decelerations
• Stem keywords: late active phase, weak and dizzy, drop in maternal B.P., late decelerations
• Lead-in keywords: initial action
• Clinical cues: The combination of maternal hypotension and late FHR decelerations is a classic sign of uteroplacental insufficiency.

Question ID

Q2xT0htOu798EuZjQ3kCVU

Copy ID

Reference Book

E6 Obstetrics Williams p. 64-85

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur pp. 28-36, 65-79