The nurse is evaluating the fetal monitor tracing of a patient who is in active labour.Suddenly the fetal heart rate (FHR)drops from its baseline of 125 down to 80.The nurse repositions the mother,provides oxygen,increases intravenous (IV)fluid,and performs a vaginal examination.The cervix has not changed.Five minutes have passed,and the FHR remains in the 80s.What additional nursing measures should the nurse take?

Question

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To relieve an FHR deceleration,the nurse can reposition the mother,increase IV fluid,and provide oxygen.If oxytocin is infusing,it should be discontinued.If the FHR does not resolve,the primary care provider should be notified immediately.Inserting a Foley catheter is an inappropriate nursing action.If the FHR were to continue in a atypical or abnormal pattern,a Caesarean birth may be warranted,which would require a Foley catheter.However,the physician must make that determination.Oxytocin may put additional stress on the fetus.

The Nurse Is Evaluating the Fetal Monitor Tracing of a Patient