Final answer:
During the fourth stage of labor with an oxytocin IV infusion, the nurse's priority is to assess the maternal blood pressure due to the potential effects of oxytocin on blood pressure. Other assessments are important but secondary in this situation. Pitocin induction aids labor progression when natural contractions are insufficient.
Step-by-step explanation:
Prioritizing the Nurse's Assessments in the Fourth Stage of Labor
While caring for a client in the fourth stage of labor who is receiving oxytocin via continuous IV infusion, the nurse's priority is to assess the maternal blood pressure. Oxytocin can have significant effects on blood pressure and may lead to hypotension, hypertension, and water retention. It is essential to closely monitor the maternal blood pressure to ensure the safety of both the mother and the newborn. Other assessments such as the fetal heart rate, perineal discomfort, and urinary output are also important but do not take precedence over monitoring the maternal blood pressure in this situation.
When labor is not progressing, as in the case of Janine, and the person is beyond 40 weeks, an IV infusion of pitocin, a synthetic form of oxytocin, is often started to induce or augment labor contractions. This intervention helps to initiate and maintain active labor, including cervical dilation, which is necessary for the baby to be born. This administration must be closely observed because of its potential impact on both maternal and fetal conditions.