The nurse notices that the fetal heart rate begins to decline from its baseline of 130 beats per minute (bpm)

24) The nurse notices that the fetal heart rate begins to decline from its baseline of 130 beats per minute (bpm) to 110bpm repeatedly after the acme of each contraction. The recording of the fetal heart shows consistent minimal variability with this fetal heart pattern. The action of the nurse should be to: a Give the laboring client oxygen via a mask b. Prepare the room and client for imminent delivery c. Start a large bore IV of Dextrose 5% in water solution d. Reposition the client into semi-fowler’s position

In this scenario, the fetal heart rate (FHR) decline from its baseline of 130 bpm to 110 bpm after the acme of each contraction, along with consistent minimal variability, suggests the presence of variable decelerations. These can indicate potential fetal distress, often associated with cord compression.

The most appropriate action for the nurse would be:

a. Give the laboring client oxygen via a mask.

Rationale:
Oxygen Administration: Providing supplemental oxygen to the laboring client can help improve fetal oxygenation and alleviate the effects of any potential fetal distress caused by decreased uteroplacental perfusion or cord compression.

Other Options:

b. Prepare the room and client for imminent delivery: While it may be necessary to prepare for delivery if fetal distress continues, it is not the immediate first step in addressing the fetal heart rate decline.
c. Start a large bore IV of Dextrose 5% in water solution: This is not directly related to managing fetal heart rate concerns and is more relevant for fluid management.
d. Reposition the client into semi-fowler’s position: While positioning can sometimes help, providing oxygen is a more direct and immediate intervention in cases of potential fetal distress indicated by the FHR pattern.
By administering oxygen, the nurse aims to enhance oxygen delivery to the fetus, thereby addressing the potential cause of the heart rate deceleration. It’s important to continue monitoring the FHR pattern and notify the healthcare provider for further evaluation and intervention.