“A nurse is caring for a patient who reports spontaneous rupture of membranes.

The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.

After calling for assistance and notifying the provider, which of the following actions should the nurse take next?”

Choice A rationale
Storing a diaphragm in sterile water after each use is not necessary. After use, the diaphragm should be washed with mild soap and warm water, then air-dried.
Choice B rationale
Using an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness.
Choice C rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is correct, but it does not address the client’s postpartum status.
Choice D rationale
The client should have her provider refit her for a new diaphragm. After childbirth, a woman’s body undergoes changes that may affect the fit of her diaphragm. It is recommended that a woman be refitted for a diaphragm around 6 weeks postpartum, when the uterus and cervix have returned to normal size.

Choice A rationale
Administering oxygen helps improve oxygenation to the fetus and is the priority intervention for late decelerations. Oxytocin is commonly used for induction and augmentation of labor. Its influence is indirect via increased uterine activity, mostly due to increased frequency of contractions or baseline pressure (hypertonus). Increase in duration or amplitude of contractions can also lead to FHR changes. The FHR changes associated with oxytocin infusion may be caused by compression of the cord with contractions or by the reduction in placental perfusion due to increased intrauterine basal pressure and frequent contractions cutting off the blood supply to the placenta. Therefore, administering oxygen can help improve the oxygen supply to the fetus.
Choice B rationale
Instructing the client to bear down and push with contractions is not the appropriate action when the fetus is experiencing persistent late decelerations. This action is more associated with the active phase of labor and not with managing fetal distress.
Choice C rationale
Amnioinfusion is a procedure where a saline solution is instilled into the uterus during labor if there is low amniotic fluid, or thick meconium is present. It is not typically used in response to late decelerations in the FHR.
Choice D rationale
Placing the client in a supine position is not the correct action. The supine position can exacerbate a condition known as supine hypotensive syndrome, where the gravid uterus compresses the inferior vena cava, reducing venous return to the heart and cardiac output. This can potentially worsen fetal distress.