A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor.
What should be the nurse’s priority action?

Choice A rationale
Late decelerations in the Fetal Heart Rate (FHR) are a type of FHR pattern observed during labor, indicating a potential compromise of fetal well-being. They often begin just after a contraction, with their lowest point occurring after the peak of the contraction. These decelerations are associated with maternal and fetal conditions. Changing the client’s position can help alleviate the pressure on the fetus and improve blood flow, potentially reducing the occurrence of late decelerations. Therefore, the first action the nurse should take when noting late decelerations in the FHR is to change the client’s position.
Choice B rationale
Applying a fetal scalp electrode is a method used to monitor the FHR more accurately. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice C rationale
Administering oxygen can help increase the oxygen supply to the fetus. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice D rationale
Increasing the rate of the IV infusion can help improve uteroplacental perfusion. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.

The correct answer is: d. Right lower

Choice A: Right upper

Reason: The right upper quadrant is not typically where fetal heart tones are auscultated when the fetal back is on the right side and the head is in the lower part of the uterus. This area is more likely to be associated with the breech presentation if the fetus’s head is in the fundus.

Choice B: Left upper

Reason: The left upper quadrant would be considered if the fetal back was on the left side and the head was in the fundus. Since the nurse palpated the fetal back on the right side, this option is not applicable.

Choice C: Left lower

Reason: The left lower quadrant would be relevant if the fetal back was on the left side and the head was in the lower part of the uterus. Given the fetal back is on the right side, this is not the correct location.

Choice D: Right lower

Reason: The correct answer is the right lower quadrant. When the nurse palpates a round, firm, movable part (likely the head) in the fundus and a long, smooth surface (the back) on the right side, it indicates that the fetus is in a cephalic (head-down) position with its back on the right. Therefore, the fetal heart tones are best auscultated in the right lower quadrant.