Difficulty: Medium
Average Score: 90%
Simulated
Passage / Scenario
Client at 39 weeks in active labor, SROM 2 hours ago, 7 cm dilated, FHR 145 bpm, moderate variability, absent accelerations, recurrent variable decelerations.The nurse is caring for a client at 39 weeks gestation in active labor. The client had a spontaneous rupture of membranes 2 hours ago with clear amniotic fluid noted. The client was 7 cm at the time of SROM. The nurse assesses the fetal heart rate monitor and identifies a fetal heart baseline of 145 bpm, with moderate variability, accelerations absent and recurrent variable decelerations. Which of the following interventions should the nurse take?
Correct answer
A,C,D,E
Rationale
Interventions for recurrent variable decelerations include notifying the provider, repositioning to the left lateral position, performing a vaginal exam for cord prolapse, and providing an IV fluid bolus to improve perfusion.