Question

a nurse is caring for a client who is in active labor and notes late decelerations...
action?

administer oxygen via face mask.
elevate the clients legs.
increase the infusion rate of the iv fluid.
position the client on her side.

Explanation:

Analyze the clinical scenario

The client is in active labor and the nurse notes late decelerations on the fetal monitor. Late decelerations indicate uteroplacental insufficiency, which reduces oxygen delivery to the fetus during contractions. This is a critical sign of fetal distress requiring immediate nursing intervention to improve placental perfusion.

Evaluate the priority intervention

The first and most immediate action to alleviate uteroplacental insufficiency caused by maternal supine hypotension or uterine compression of the vena cava is to change the mother's position. Turning the client to her side (lateral position, preferably left-lateral) shifts the weight of the pregnant uterus off the inferior vena cava and abdominal aorta, immediately improving venous return, cardiac output, and placental blood flow.

Compare alternative interventions

• Administer oxygen via face mask: This is a correct intervention for late decelerations, but it should be done after or in conjunction with repositioning the client, as oxygenation is ineffective if blood flow to the placenta is mechanically obstructed.
• Elevate the client's legs: This is not the primary intervention for late decelerations and does not relieve aortocaval compression.
• Increase the infusion rate of the IV fluid: This is also a standard part of intrauterine resuscitation to correct maternal hypotension, but repositioning remains the quickest, non-invasive first step.

Determine the first action

According to standard obstetric protocols (such as ACOG guidelines), the very first action when late decelerations are identified is to position the client on her side to maximize uterine blood flow.

Answer:

• Administer oxygen via face mask.
• Elevate the client's legs.
• Increase the infusion rate of the IV fluid.
• Position the client on her side. (Correct answer)