Examkin

Question

Difficulty: HardAnte/Intra/Postpartum and Newborn Care

A nurse is caring for a client at 40 weeks gestation who is receiving a continuous transcervical amnioinfusion for the management of recurrent, severe variable decelerations. The nurse evaluates the electronic fetal monitor and intrauterine pressure catheter (IUPC) data. The fetal heart rate baseline is 145 bpm with moderate variability, and the variable decelerations have ceased. However, the nurse observes that the uterine resting tone has steadily increased from 15 mm Hg to 45 mm Hg over the past 20 minutes, and the client's perineal underpads are completely dry. Which of the following is the nurse's priority action?

  1. Stop the amnioinfusion pump immediately.Answer
  2. B
    Assist the client into a left lateral recumbent position.
  3. C
    Prepare to administer a prescribed dose of subcutaneous terbutaline.
  4. D
    Perform a sterile vaginal examination to assess for a prolapsed umbilical cord.

Answer

The priority action is to stop the amnioinfusion pump immediately to prevent uterine overdistention and potential uterine rupture.
The assessment findings of a steadily increasing IUPC resting tone (normal is 10-20 mm Hg) combined with a lack of vaginal fluid return (dry underpads) indicate that the amnioinfusion fluid is being trapped inside the uterus. This creates dangerous uterine overdistention, which severely increases the risk of uterine rupture or abruptio placentae. The immediate priority is to stop the pump to halt further fluid accumulation.

Step-by-Step Solution

1
Analyze the purpose of the treatment and the current fetal status.
The amnioinfusion successfully resolved the variable decelerations, and the fetal heart rate is currently stable and reassuring.
Establishes that there is no immediate fetal distress requiring interventions like maternal repositioning.
2
Evaluate the intrauterine pressure catheter (IUPC) data and physical assessment findings.
The IUPC resting tone is dangerously high (45 mm Hg), and the dry perineal pads indicate no fluid is draining out.
Normal resting tone should remain between 10-20 mm Hg. The discrepancy between input and output indicates fluid retention.
3
Determine the physiological risk of the assessment findings.
Retained amnioinfusion fluid causes severe uterine overdistention, placing the client at imminent risk for uterine rupture.
The uterus is a confined space; adding continuous fluid without drainage drastically increases intrauterine pressure.
4
Select the most direct and immediate intervention.
Stopping the amnioinfusion pump is the priority.
It immediately halts the source of the rising pressure, preventing catastrophic uterine trauma.

Key Concept

Amnioinfusion complications and management of uterine overdistention
Rate this question

Topics

Ante/Intra/Postpartum and Newborn Care

More questions from this topic