NCLEX: intrapartum

• • Administer oxygen to the client
• • Change the client’s position
• • Contact the healthcare provider

• Use STOP:
• 1) stop oxytocin (pitocin)
• 2) turn Pt on lateral side
• 3) O2 admin via nonrebreather mask
• 4) Give IV bolus of LR or NS.
• 5) Notify HCP

Late decelerations are caused by placental insufficiency and need to have an active response. Increasing the pitocin would cause the fetus to have further placental insufficiency. Discontinuing the external fetal heart monitor would be inappropriate as the fetus needs intervention. Calling the healthcare provider would be necessary for a change in the plan of care. Application of oxygen to the client would help facilitate further oxygenation of the fetus. Changing the client’s position may help alleviate the decelerations if they are caused by hypotension and will help determine if the decelerations are truly late.

After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information.