RN Nursing · Fetal Heart Rate Monitoring · Practice question
A nurse reviews the most recent assessment findings. What actions should the nurse take. (Select all that apply.)
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Apply oxygen at 10 L by nonrebreather mask.
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Decrease the rate of the oxytocin infusion.
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Request a prescription for an amnioinfusion .
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Discontinue the magnesium infusion
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Administer calcium gluconate
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Infuse a 500 ml bolus of lactated Ringer's.
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Collect a specimen for a fetal fibronectin test
Answer & explanation
Correct: Apply oxygen at 10 L by nonrebreather mask. · Decrease the rate of the oxytocin infusion. · Request a prescription for an amnioinfusion . · Infuse a 500 ml bolus of lactated Ringer's.
For a category II/III fetal heart rate tracing with late or variable decelerations, intrauterine resuscitation measures include applying oxygen at 8–10 L/min by nonrebreather mask to increase fetal oxygenation; decreasing or stopping oxytocin to reduce uterine activity; requesting amnioinfusion to relieve cord compression causing variable decelerations; and giving an IV fluid bolus of lactated Ringer's to improve placental perfusion. Magnesium would be discontinued only for toxicity, and calcium gluconate is the antidote for magnesium toxicity—neither addresses fetal distress. Fetal fibronectin is used to assess preterm labor risk, not to manage acute fetal compromise (AWHONN intrapartum fetal monitoring).
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