A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound.
When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse’s first intervention should be to:
A . Check FHT
B . Notify the attending physician
C . Turn off the IV oxytocin
D . Prepare for the delivery because the client is probably in transition
Answer: C
Explanation:
(A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care.
(B) The physician should be notified, but this is not the first intervention the nurse should do.
(C) The standard of care for an induction according to the Association of Women’s Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus.
(D) Contractions lasting 60C90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
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