The nurse assesses a prolonged late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing intervention would be to:
A. Turn off the infusion.
B. Turn the client to the left.
C. Change the fluid to Ringer’s Lactate.
D. Increase mainline IV rate.
Correct Answer: A. Turn off the infusion
Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration. When late decelerations are observed, the nurse should attempt to increase the oxygen delivery to the fetus by turning the mother on her left side and/or administering oxygen. If Oxytocin (Pitocin) is being administered, it should be stopped.
Option B: Variable decelerations are marked by a sharp decrease (“V” shape) in FHR that does not correlate to contractions. Umbilical cord compression is usually the cause of variable decelerations. Repositioning of the mother can relieve this compression if it is minor.
Option C: Late decelerations are shown by the FHR gradually decreasing around the peak of the contraction and gradually increasing when the contraction is over. These decelerations will also have a “U” shape but will not mirror the contractions. The most common cause of late decelerations is uteroplacental insufficiency (insufficient oxygen exchange between the placenta and the fetus).
Option D: Increasing the main IV line would not manage the decelerations. While caring for a patient in labor, one of the important nursing duties is monitoring the variability of the fetal heart rate (FHR) and monitoring the FHR response during contractions. Variability in the FHR during labor is a sign of fetal well-being or fetal activity or both. The expected variability usually includes slight accelerations and decelerations.