Difficulty: Medium
Average Score: 79%
Simulated
Passage / Scenario
Client is a 26-year-old gravida 3 para 2 at 39 weeks gestation being induced for oligohydramnios. No significant social or medical history. Only complication is oligohydramnios. Previously delivered a 7-pound, 5-ounce infant vaginally without complications. Upon admission: 1 cm, 40% effaced, -2 station. No bloody show. Induced via Foley bulb induction. At 1200: 6 cm, 70% effaced, 0 station, membranes intact. Contractions every 2-3 min, strong. Fetal heart rate 140-145/min with average variability, drops to 100/min with contractions, lasts 20 sec, returns to baseline within 30 sec. Vital Signs at 1000: BP 122/74 mm Hg, HR 98/min, RR 20/min, Temp 36.7°C (98.1°F), O2 sat 99% on room air.Complete the diagram by dragging from the choices below to specify what complication the client is most likely experiencing, 2 actions the nurse should take to address that complication, and 2 parameters the nurse should monitor to assess the client's progress. Actions to take:
Rationale
Variable decelerations, indicated by a drop to 100/min with contractions, suggest cord compression due to oligohydramnios. Turning the client to the left side relieves cord pressure, and amnioinfusion adds fluid to cushion the cord. Monitoring fetal heart rate baseline and uterine contraction strength assesses intervention effectiveness.