Question

Eight hours later, the oxytocin dosage is at 16 mu/min (16 mL/hr). Aminiah's vitals: T 37.4 C, 99.3 F, Pulse 94 bpm and regular, BP 128/84 mmHg. Pain level 8/10 with some involuntary "grunting" at the peak. Client has tears coming down her cheeks. Her husband is pacing in room. The midwife rubs her back and coaches her in breathing. FHR baseline 145 with moderate variability. Contraction pattern: q2min, 90 second duration, strong. There have been 6 contractions in 10 minutes. Fetal heart tones decelerate to 80 beats/minute during the contraction but does not return to baseline at the end of the contraction. The midwife conducts a sterile vaginal exam to check for cervical dilation and assess for umbilical cord prolapse. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

a. Discontinue the oxytocin infusion.Tachysystole is defined as more than 5 contractions in 10 minutes. When this occurs related due to stimulated labor, the nurse should immediately discontinue the oxytocin infusion.
b. Reposition the client to the other side.Side lying position decreases pressure on the vena cava and increases perfusion to the placenta and fetus. This intervention may be done quickly.
c. Administer oxygen via nonrebreather face mask at 10 L/min.Enhance oxygenation to the fetus by administration of 100% oxygen to the mother. This intervention is quickly and may be done if the first two actions are not effective.
d. Administer IV fluid bolus of 500 mL/hr.Late decelerations do not return to baseline at the end of the contraction as a result of fetal hypoxemia. A fluid bolus will increase maternal BP and perfusion to the fetus. This intervention is completed if the first 3 actions are not effective to relieve tachysystole and fetal distress.
e. Administer terbutaline 0.25 mg subcutaneously.Terbutaline is a tocolytic to relax the uterine smooth muscle and relieve tachysystole. This is the last action, if the other interventions do not relieve fetal distress.

Answer 1

The first action is to discontinue the oxytocin infusion due to tachysystole, followed by repositioning the client to her side to improve fetal blood flow and oxygen delivery. Both are urgent to address fetal distress.

Step-by-step explanation:

In the scenario provided, the first nursing action to be implemented is discontinuing the oxytocin infusion. Tachysystole, defined as more than 5 contractions in 10 minutes, has occurred, possibly due to simulated labor from oxytocin. This can potentially contribute to fetal distress, marked by fetal heart tones that do not recover post-contraction. Stopping oxytocin can help reduce the contraction frequency and intensity.

The second action is repositioning the client to her side. A side-lying position is beneficial as it can minimize compression on the vena cava, thus enhancing blood flow and oxygen delivery to the placenta and fetus. This is a quick intervention that might immediately improve fetal heart rate decelerations and overall fetal status.

Given the significance of the umbilical cord in providing oxygen and nutrients to the fetus, careful monitoring and quick response to signs of fetal distress are crucial during labor. These two actions prioritize the immediate wellness of both mother and child.