A nurse is caring for a laboring client who is receiving an intravenous oxytocin infusion for labor augmentation. Upon reviewing the electronic fetal monitor tracing, the nurse notes a pattern of recurrent late decelerations. In which order should the nurse perform the following interventions? (Arrange the actions in the correct sequence from first to last.)
- 1Discontinue the oxytocin infusion.
- 2Reposition the client into a lateral side-lying position.
- 3Administer oxygen at 8 to 10 L/min via a nonrebreather face mask.
- 4Administer a bolus of intravenous crystalloid fluid.
- 5Notify the primary healthcare provider.
Cevap
The correct sequence is to first discontinue the oxytocin infusion, then reposition the client to a lateral side-lying position, administer oxygen, administer a bolus of intravenous fluid, and finally notify the healthcare provider.
Recurrent late decelerations indicate uteroplacental insufficiency. The nurse must immediately initiate intrauterine resuscitation steps to optimize fetal oxygenation. The sequence is driven by physiological priorities: first, stop any factors decreasing perfusion (discontinuing oxytocin); second, mechanically improve perfusion by relieving vena cava compression (lateral positioning); third, maximize the oxygen available in the maternal blood (oxygen administration); fourth, increase circulating volume to deliver that oxygen (intravenous fluid bolus); and finally, escalate the situation to the healthcare provider once these immediate stabilizing actions are in progress.
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Anahtar Kavram
Intrauterine Resuscitation for Late Decelerations