What is an appropriate response if a nurse observes late decelerations in fetal heart rate?

• A. Administer glucose
• B. Prepare for cesarean birth, if ordered
• C. Do nothing and wait
• D. Continue monitoring without changes

Answer: (B)

The observation of late decelerations in fetal heart rate is an indicator of potential fetal distress, often associated with uteroplacental insufficiency. This situation typically signifies that the fetus may not be receiving adequate oxygen, and timely intervention is critical to ensure the safety of both the mother and the fetus.

Preparing for a cesarean birth, if ordered, is appropriate because it may be necessary to expedite delivery to prevent further complications. This intervention is aimed at promptly addressing the concerns raised by the late decelerations, as continuing with the current management without taking action could lead to serious risks for the fetus. The nurse’s responsibility in this circumstance is to ensure that all necessary preparations are initiated swiftly, in coordination with the healthcare team, to facilitate a safe delivery.

Other responses, such as administering glucose or simply continuing monitoring without changes, do not address the urgency of the situation effectively. Waiting or doing nothing would not be advisable, as it could jeopardize fetal well-being. Thus, the most appropriate response involves preparing for a possible cesarean delivery, reflecting the need for immediate action in the context of abnormal fetal heart rate patterns.