Question

A nurse is caring for a client who is pregnant.

Medical History
Gravida 1, Para 041 weeks of gestationInduction of labor due to postdates
Nurses' Notes
1400:Client received epidural anesthesia for reports of a pain level of 7 on a scale of 0 to 10 from uterine contractions.Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate.FHR: Baseline 135/min, average variability, accelerations present, no decelerations noted.Oxytocin infusing at 8 milliunit/min. Rate last increased by 2 milliunits/min at 1330.
1415: Client reports feeling light-headed.Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderateFHR: Prolonged deceleration of fetal heart rate to 90/min, minimal variability.
Vital Signs
1400: Temperature 37.1° C (98.8° F)Heart rate 72/minRespirations16/minBlood pressure 128/76 mm HgOxygen saturation 96%1415:Heart rate 90/minRespiratory rate 20/minBlood pressure 92/50 mm HgOxygen saturation 96%

Which of the following actions are the nurse's priorities?
Select the 4 actions that the nurse should take immediately.

Answer 1

The nurse should immediately notify the healthcare provider, administer oxygen, discontinue the oxytocin, and position the client on her left side, prioritizing the safety and well-being of both the mother and fetus.

Step-by-step explanation:

The priority actions that the nurse should take immediately for a pregnant client who is at 41 weeks gestation and experiencing changes in vital signs and fetal heart rate (FHR) after receiving epidural anesthesia and oxytocin for induction include:

• Notifying the healthcare provider immediately due to the signs of potential fetal distress and maternal hypotension.
• Administering oxygen to the client to increase oxygen delivery to the fetus.
• Discontinuing the oxytocin infusion as it may contribute to the observed fetal heart rate changes and the client's hypotension.
• Positioning the client on her left side to improve uteroplacental blood flow, thereby potentially improving fetal oxygenation.

It is imperative to address the prolonged deceleration of the fetal heart rate and the client's drop in blood pressure as these can signal fetal distress and maternal hypotension, respectively. Both conditions need urgent intervention to ensure the well-being of both the mother and fetus.