The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first ?

The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first ?
The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first ?
  • reposition the client
  • draw a potassium level
  • notify the health care provider
  • prepare the client for a cesarean section
Number 1 is correct.
The fetal heart tone strip shows variable decelerations, which are caused by umbilical cord compression. The nurse should reposition the client. Drawing a potassium level will not resolve the problem. The health care provider does not need to be notified unless decelerations worsen after repositioning. There is no indication at this time for a cesarean section.