Practice Question
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/minute, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
Answer Choices:
Correct Answer:
Discontinue the infusion of the IV oxytocin.
Rationale:
🔴 The uterine contractions occurring every 2 minutes and lasting 90 seconds indicate uterine tachysystole, which is defined as more than 5 contractions in 10 minutes, potentially compromising fetal oxygenation.
🔴 The presence of uniform decelerations beginning at the peak of contractions and returning after suggests late decelerations, which are associated with uteroplacental insufficiency.
🔴 Oxytocin, a uterotonic agent, can lead to overstimulation of the uterus, increasing the risk of fetal distress and hypoxia.
🔴 The immediate action is to discontinue the oxytocin infusion, allowing the uterus to rest and improving fetal perfusion.
🔴 Additional actions may include repositioning the patient, administering oxygen, and notifying the provider, but the first priority is stopping the agent causing the excessive contractions.
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This question is from RN ATI Maternity Exam IV which contains 68 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 4