Difficulty: Medium
Average Score: 70%
Simulated
Passage / Scenario
A client at 3 weeks of gestation in early active labor with contractions every 3-4 minutes, oxytocin infusion, LOA vertex, 4 cm dilation, complete effacement, FHR decelerations to 100/minA nurse is assisting in the care of a client who is at 3 weeks of gestation. The client presents to the Labor and Delivery Unit in the early phase of active labor with contractions occurring every 3 to 4 minutes. An 18-gauge needle is inserted in the left hand and oxytocin infusion is initiated. An internal examination reveals a left occiput anterior (LOA) vertex, 4 cm dilation, complete effacement, and decelerations noted in the fetal heart rate (FHR) which decreases to 100/min with contractions, lasts 10 seconds, and returns to baseline within 20 seconds. What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client's progress?
Correct answer
B,C
Rationale
FHR decelerations suggest potential fetal distress, requiring continued monitoring of contractions and fetal heart rate, and ensuring comfort and hydration to support labor.