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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

While evaluating the labor progress of a gravida 2, para 1 client receiving oxytocin augmentation, the nurse identifies a gradual, symmetric decrease in the fetal heart rate that begins consistently after the peak of successive contractions. The heart rate returns to baseline only after the contraction has fully resolved. Which intervention is the most appropriate initial action?

  1. A
    Page the obstetric provider immediately to report the findings.
  2. Stop the intravenous oxytocin administration.Answer
  3. C
    Record the rhythm as a benign finding caused by cranial compression.
  4. D
    Set up the room for an immediate amnioinfusion.

Answer

The correct action is to stop the intravenous oxytocin administration to improve uteroplacental perfusion.
The fetal heart rate pattern described indicates late decelerations, which are a sign of uteroplacental insufficiency. When a client is receiving an oxytocin infusion, the medication forces the uterus to contract, which further decreases blood flow to the placenta. Therefore, the absolute first priority is to stop the oxytocin infusion to decrease uterine activity, thereby improving blood flow and oxygenation to the compromised fetus.

Step-by-Step Solution

1
Analyze the described fetal heart rate (FHR) pattern.
The gradual decrease starting after the contraction peak and recovering after the contraction ends defines a late deceleration.
Accurate interpretation of electronic fetal monitoring is essential to distinguish between benign and pathological patterns.
2
Determine the physiological cause of the identified pattern.
Late decelerations are caused by uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen during contractions.
Understanding the cause dictates the appropriate clinical intervention.
3
Prioritize the necessary nursing interventions for intrauterine resuscitation.
The immediate priority is to maximize fetal oxygenation by removing stressors (stopping oxytocin), repositioning the mother, and administering oxygen.
According to the ABCs and prioritization principles, direct actions that restore physiological stability take precedence over documentation or provider notification.

Key Concept

Intrauterine Resuscitation and Electronic Fetal Monitoring Interpretation
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Topics

Ante/Intra/Postpartum and Newborn Care

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