NCLEX: Interventions for Late Decelerations

  1. Please help . I will take the NCLEX soon and I have come across some conflicting information. The KAPLAN question below indicates that with late decelerations during labor, the first thing we should do is shut off the pitocin. However the KAPLAN book as well as other web resources, including this thread at AllNurses (, indicates that the order of interventions should be :

    1. LLR position
    2. O2 @ 8-10 LPM
    3. Increase IV Fluid
    4. Pit off
    5. Call MD

    You switch to the LLR first because it is the quickest and easiest intervention to take and do that while you get her oxygen going. Then you keep going down the list.

    KAPLAN Question:

    The nurse cares for a client in labor undergoing augmentation. The nurse notes 3 consecutive late decelerations on the client’s electronic fetal monitor tracing. Which of the following actions should the nurse take FIRST?

    1. Turn off the infusion of oxytocin (Pitocin).
    2. Turn the client to her left side.
    3. Apply O2 by mask at 10 L of oxygen.
    4. Increase the infusion of lactated Ringer’s solution.


    Strategy:“FIRST”indicates priority.

    1) CORRECT - priority action; cause must be stopped before implementing measures to increase oxygen flow to the fetus

    2) increase placental perfusion, but must stop Pitocin first

    3) increase the amount of circulating oxygen; but must stop Pitocin first

    4) increasing the rate of fluid administration not indicated; used for fluid volume deficit

    What will the NCLEX test expect? Thank you.
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  3. by   xtxrn
    Try this-

    What is the risk to the baby w/late decels?
    A-B-C s
  4. by   Jolie
    I hate these artificial questions, because, in reality, you CAN turn off the pit as you assist the patient to her L side, and reach up and start the O2 at the same time.

    But, if forced to choose, I would turn off the pit first. While it has a very short 1/2 life, it won't begin to clear the mother's blood stream until it has been turned off for a minute or 2. The other interventions will have immediate effect.

    I have a problem with the "correct answer" stating that discontinuing the pit is the LAST step you would take with the patient.
  5. by   truckinusa
    ATI says the same thing. Discontinue IV medication

    A nurse who is caring for a client in labor. The client is receiving a oxytocin(pitocin) by continuous IV infusion, piggybacked into a maintenance IV solution. The external FHR monitor indicates late deccerations. Which of the following actions should the nurse take?
  6. by   fem
    I'm studying the same topic. Per ATI's book = RN Maternal Newborn Nursing Edition 8.0, p173, it states the initial Nursing Action
    is to "reposition the client in to Left Lateral Position". The ATI non-proctored test says the next step is to D/C the oxytocin (Pitocin).

    I'm so frustrated when the professor tells you one thing and the ATI exam tells you something else.
    If you don't pass the Professor's exams, you never even get to to take the NCLEX.
    But seems like what Professor's teach should be consistent with NCLEX questions.
    Ok, rant over. LOL.
  7. by   Wildcats.Cabral
    I had the same conflict in an exam last week. As previous poster stated, we have to pass professor's exam right now, so go with their answer, which was O2, reposition, Pitocin, etc. Other study guides were similar to other information stated, IV, reposition, O2.
  8. by   suppaduppaCNA
    Discontinue IV first because baby at greater risk for uteroplacental insufficiency if uterine contraction continue. (Source:ATI).
    Now If I have an issue like yours I will ask the instructor what's his/her rationale because I want to learn the right way.(if there is one...)
  9. by   fem
    It is frustrating when the same source (ATI) states 2 different approaches to implementation.

    And yes, I've observed this type of conflict even in the same textbook & edition.... Just a different page.
    When I've pointed this out to 2 or 3 different instructors, I'm told "don't worry about it".
    Best advice one instructor gave me was "When in Rome, do as the Romans do; Each hospital has policy & protocols".
  10. by   LiveFit99
    Sorry to post such an old thread but I just had this on ATI. Echoing my frustration with this "first intervention" questions. Truth is you would do them all in a span of about 15 seconds so the point is rather moot. Also, I did some specific FHR training and the intervention was almost always to reposition first.

    While I understand "follow hospital policy" that doesn't help us get poor questions correct that affect our GPA.
  11. by   decandjl
    I hate to bring up an old topic, but I did want to reply to your post LiveFit99. This is what I'm getting from my text book:

    • Stop oxytocin immediately
    • Reposition or maintain the side-lying position
    • Apply oxygen at 10 L/min via face mask
    • Give IV fluid bolus
    • Consider giving terbutaline subcutaneously
    • Notify the health care provider
    • Document the findings
  12. by   LiveFit99
    Thanks for input. Luckily I already passed nclex!

    I understand rationale to stop pitocin but still find sources saying reposition first too.

    For one, my class was taught that least invasive intervention is preferred, and reposition would be less invasive than changing medication.

    However I now no longer care because the real answer is I will do what I'm taught at the hospital. Suck it ATI and NCLEX with your silly questions!