Nursing

Assessment Planning Intervention Rationale Evaluation

Diagnosis

Risk for fetal At the end of Independent o Goal met as

injury related nursing care evidenced by
to prolonged during the Assess FHR o Detects FHR returned to
deceleration labor manually or abnormal normal range
electronically. responses, such
The FHR will Note variability, as exaggerated o Labor resulted to
be at the periodic changes, variability, NSVD of a 5 lbs. 12
normal range and baseline rate bradycardia, and oz.
110 bpm to tachycardia,
160 bpm> which may be o Newborn Apgar
The patient caused by score is 9
should be stress, hypoxia,
able to acidosis, or
deliver the sepsis
new born
normally Note frequency o Contractions
of uterine occurring every
contractions. 2 minors less do
Notify physician if not allow for
the frequency is 2 adequate
min or less. oxygenation of
intervillous
spaces

Monitor fetal o Descent that is

descent in birth less than 2
canal in relation cm/hr. for a
to ischial spines multipara, may
indicate CPD or
Turn patient to malposition
left side

Dependent

Administer o To alleviate
lactated ringers decelerations.
intravenously
o To replace fluid
and buffer ph.
to prevent
acidosis if the
cause of
deceleration is
cord
compression