1. monitoring fetal status
Rationale:
The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.
1.1. Question
A nurse is caring for a client in labor who is receiving Pitocin by IV
infusion to stimulate uterine contractions. Which assessment
finding would indicate to the nurse that the infusion needs to be
discontinued?
o A. Three contractions occurring within a 10-minute period
o B. Increased urinary output
o C. Adequate resting tone of the uterus palpated between
contractions
o D. A fetal heart rate of 90 beats per minute
Incorrect
Correct Answer: D. A fetal heart rate of 90 beats per
minute
A normal fetal heart rate is 120-160 BPM. Bradycardia or late or
variable decelerations indicate fetal distress and the need to
discontinue Pitocin. The goal of labor augmentation is to achieve
three good-quality contractions in a 10-minute period.
oOption A: Pitocin (oxytocin injection) is a natural
hormone that causes the uterus to contract used to
induce labor, strengthen labor contractions during
childbirth, control bleeding after childbirth, or induce
an abortion.
oOption B: Oxytocin has an antidiuretic effect and
increases the urinary excretion of AQP2 in humans
whose urinary concentration mechanism is preserved.
Urine volume and free water clearance were
decreased, and urine osmolality was increased by the
administration of oxytocin or dDAVP in the normal
volunteers and CDI patients.
oOption C: In a normal labor, one contraction every
two to three minutes or less than five contractions in a
10 minute period is ideal. A uterus must rest between
contractions, having sufficient uterine resting tone
(soft to the touch), and uterine resting time (about one
minute).
2.2. Question