88. A client, who is gravida 3, para 1, is being induced for pregnancy-induced hypertension using IV oxytocin. Under which circumstances should a nurse discontinue infusion of oxytocin? Select all that apply.
88. A client, who is gravida 3, para 1, is being induced for pregnancy-induced hypertension using IV oxytocin. Under which circumstances should a nurse discontinue infusion of oxytocin? Select all that apply.
. Three contractions in a 10-minute window of time.
. Contractions every 3 minutes, lasting 90 seconds each.
. Decrease in fetal heart rate after the peak of the contraction during each of the last three contractions.
. Five contractions in the past 8 minutes.
. Client is completely dilated.
Test-Taking Tip
Draw out the pattern of contractions described to see if the contractions are too frequent or too long as reasons for stopping the oxytocin.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Interactions
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Answer 1 is incorrect because 3 contractions in a 10-minute window is a normal pattern for contractions, and not a reason to discontinue the oxytocin infusion. Answer 2 is correct because contractions that occur every 3 minutes, lasting 90 seconds, do not allow adequate resting time for the uterus, and the oxytocin should be discontinued. Answer 3 is correct because this pattern describes late decelerations, which are a sign of fetal distress, and the oxytocin should be discontinued. Answer 4 is correct because more than 5 contractions in a 10-minute window is hyperstimulation, and the oxytocin should be discontinued. Answer 5 is incorrect because being completely dilated is not a reason to discontinue the oxytocin infusion. Contractions are still needed for the second stage of labor. Discontinuing the oxytocin may decrease the number of contractions and increase the length of the second stage.