The nurse is caring for a client receiving an intravenous oxytocin infusion to induce labor. The nurse observes that the client’s uterus has been contracting continuously for the past five minutes. The fetal heart rate is 95 beats per minute.
Which of the following actions should the nurse take?
The nurse is caring for a client receiving an intravenous oxytocin infusion to induce labor. The nurse observes that the client’s uterus has been contracting continuously for the past five minutes. The fetal heart rate is 95 beats per minute.
Which of the following actions should the nurse take?
A. Place the client in a Trendelenburg position
[5%]
B. Stop the oxytocin infusion
[84%]
C. Administer oxygen via nasal cannula
[9%]
D. Perform a vaginal exam
[3%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Labor/Delivery
Client Need
Test Plan
Physiological Adaptation
Related Topic
Unexpected Responses to Therapies
Item Type
Item Type
Application
Explanation
Choice B is correct. Oxytocin is used to induce labor at or near full-term gestation and to enhance labor when uterine contractions are weak and ineffective. Here, when the nurse notices the client's fundus has been contracting continuously for the past five minutes, and an assessment of fetal heart rate reveals 95 beats per minute, the nurse should immediately recognize these symptoms as evidence of fetal distress. The priority action is for the nurse to stop the oxytocin infusion.
Choice A is incorrect. The nurse should place the client in a side-lying position to aid in improving fetal circulation. Placing a client in a Trendelenburg position is used in situations of cord prolapse.
Choice C is incorrect. While oxygen may be beneficial, it is not the initial intervention. Administering oxygen without addressing the cause of uterine hyperstimulation does not treat the problem. Additionally, oxygen supplementation should be administered via a face mask.
Choice D is incorrect. A vaginal exam may be needed later to assess for cord prolapse or cervical changes, but it does not address the immediate concern of excessive uterine activity and fetal bradycardia.
Learning Objective
Identify the signs and symptoms of fetal distress, correlate the fetal distress to the oxytocin infusion, and recognize the need to stop the oxytocin infusion immediately.
Related Videos
4 Key Topics
Oxytotic Medications
6.13 Obstetric & Labor Medications
Tocolytics & Oxytotics
30.2 Preterm Labor & Medications
Additional Info
✓ Oxytocin is also used to prevent or control uterine bleeding after delivery, to induce completion of an incomplete abortion (including miscarriages), and to promote milk ejection during lactation.
✓ During the infusion, the fetal heart rate (FHR) should be monitored closely for non-reassuring patterns. The normal FHR is 110-160/minute.
✓ Uterine tachysystole (≥12 uterine contractions in 20 minutes without an alteration in the fetal heart rate pattern) may be caused by oxytocin.
