Question

A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes.

1.Stop of Pitocin infusion
2.Perform a vaginal examination
3.Reposition the client
4.Check the client's blood pressure and heart rate
5.Administer oxygen by face mask at 8 to 10 L/min

Answer 1

The nurse should stop the Pitocin infusion, check the client's vital signs, reposition the client, administer oxygen, and perform a vaginal examination in order of priority.

Step-by-step explanation:

The nurse should prioritize the following actions:

1. Stop the Pitocin infusion - Hypertonic uterine contractions may be caused by an excessive amount of Pitocin. Stopping the infusion will help alleviate the contractions.
2. Check the client's blood pressure and heart rate - This is important to assess the client's overall condition and monitor for any signs of distress or complications.
3. Reposition the client - Changing the client's position can help relieve the discomfort caused by hypertonic contractions and improve fetal blood circulation.
4. Administer oxygen by face mask at 8 to 10 L/min - Oxygen supplementation can be helpful in providing relief during labor and ensuring adequate oxygenation for both the mother and the baby.
5. Perform a vaginal examination - This action can provide additional information about the progress of labor but is of lower priority compared to the above actions.