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Zorluk: OrtaAnte/Intra/Postpartum and Newborn Care

A client in the active phase of labor is receiving an intravenous oxytocin infusion to augment uterine contractions. While monitoring the client, the nurse observes that the fetal heart rate gradually decreases, with the lowest point of the deceleration occurring consistently after the peak of each uterine contraction. The fetal heart rate slowly returns to baseline after the contraction ends. Which of the following is the priority nursing action?

  1. Stop the continuous intravenous oxytocin infusion immediately.Cevap
  2. B
    Record the pattern as a normal physiological response to fetal head compression.
  3. C
    Instruct the unlicensed assistive personnel to increase the primary intravenous fluid rate.
  4. D
    Continue current monitoring and prepare to reassess the fetal heart rate in 30 minutes.

Cevap

Stop the continuous intravenous oxytocin infusion immediately.
The pattern described is a late deceleration, which indicates uteroplacental insufficiency and potential fetal hypoxia. When a client is receiving oxytocin, the priority action is to immediately stop the infusion. This decreases uterine activity, which allows placental blood flow and fetal oxygenation to improve.

Adım Adım Çözüm

1
Analyze the described fetal heart rate pattern.
The decelerations reach their nadir after the peak of the contraction and return to baseline after the contraction ends, which defines a late deceleration.
Accurate interpretation of electronic fetal monitoring is essential to determine fetal well-being.
2
Identify the underlying physiological cause of the pattern.
Late decelerations are caused by uteroplacental insufficiency, meaning the fetus is experiencing hypoxia during contractions.
Understanding the cause directs the appropriate resuscitative interventions.
3
Determine the highest priority nursing intervention.
The most immediate action is to stop the oxytocin infusion.
Oxytocin causes uterine contractions. Stopping it reduces uterine activity, which immediately improves blood flow and oxygen delivery to the placenta and fetus.

Anahtar Kavram

Intrauterine resuscitation for late decelerations
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Konular

Ante/Intra/Postpartum and Newborn Care

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