Question

A nurse is caring for a client who is in labor. the client is receiving oxytocin by continuous IV infusion with a maintenance iv solution. the external FHR monitor indicates late decelerations. which of the following actions should the nurse take first?

(a) Discontinue the oxytocin infusion.

(b) Notify the healthcare provider.

(c) Position the client on her left side.

(d) Administer oxygen to the client via a non-rebreather mask.

Answer 1

The nurse should first discontinue the oxytocin infusion in response to late decelerations on the fetal heart rate monitor.

Step-by-step explanation:

The nurse should take the action of discontinuing the oxytocin infusion first. Late decelerations on the fetal heart rate monitor indicate a decrease in blood flow to the placenta, which can be caused by uterine hyperstimulation from the oxytocin infusion. Discontinuing the infusion will help alleviate the hyperstimulation and prevent further harm to the baby.