NCLEX-RN practice › Health Promotion and Maintenance
NCLEX maternity question: Category III fetal heart tracing (SATA)
Health Promotion and Maintenance · Select all that apply · Clinical judgment step: Take action
Client record
Fetal monitoring
| Feature | Last 30 minutes |
|---|---|
| Baseline FHR | 150/min |
| Variability | Absent |
| Accelerations | None |
| Decelerations | Recurrent late decelerations with every contraction |
Contractions
Every 2 minutes, lasting 80 seconds
Oxytocin 12 milliunits/min
Maternal
BP 112/70 mm Hg, HR 92/min, Temp 37.0 °C
A client at 39 weeks in active labor is receiving oxytocin. The nurse reviews the fetal monitoring summary. Which actions should the nurse take? Select all that apply.
- A. Notify the provider and prepare for expedited birth
- B. Document the tracing and reassess in 30 minutes
- C. Stop the oxytocin infusion
- D. Give an IV fluid bolus
- E. Place the client supine for continuous monitoring
- F. Turn the client to a lateral position
- G. Increase the oxytocin to speed delivery
Show the answer and rationales
Answer: A, C, D, F
Absent variability with recurrent late decelerations is a Category III tracing showing fetal acidemia. Intrauterine resuscitation (stop oxytocin, reposition, fluids, oxygen as per policy) and preparation for expedited birth are needed.
- A. Correct. Absent variability with recurrent late decelerations is a Category III tracing; if not resolved promptly, birth is expedited.
- B. Incorrect. A Category III tracing requires immediate action, not watchful waiting.
- C. Correct. Removing the stimulus to contract improves uteroplacental blood flow.
- D. Correct. A bolus increases maternal circulating volume and placental perfusion.
- E. Incorrect. The supine position compresses the vena cava and reduces placental blood flow.
- F. Correct. Lateral positioning relieves aortocaval compression and improves placental perfusion.
- G. Incorrect. More oxytocin would worsen fetal hypoxia.
Scoring: select all that apply items on the Next Generation NCLEX use plus/minus scoring. You gain a point for each correct option you choose and lose a point for each incorrect one, with a minimum of zero. This item is worth 4 points.
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