Question

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate?

1.Encourage the client's coach to continue to encourage breathing exercises
2.Encourage the client to continue pushing with each contraction
3.Continue monitoring the fetal heart rate
4.Notify the physician or nurse mid-wife

Answer 1

The nurse should notify the physician or nurse midwife because a fetal heart rate of 100 BPM could indicate fetal distress, requiring immediate attention. The use of pitocin for Janine is to induce stronger and more frequent contractions to progress labor. The newborn's circulatory pattern changes significantly after taking the first breath, transitioning from fetal to neonatal circulation.

Step-by-step explanation:

A nurse monitoring a client in active labor notes contractions every 3 minutes, lasting 45 seconds, and a fetal heart rate (FHR) of 100 BPM between contractions. The most appropriate nursing action is to notify the physician or nurse midwife. This low FHR could indicate fetal distress, which may be due to inadequate relaxation between contractions, not allowing for proper oxygenation of the fetus. Timely intervention is critical to ensure the safety of both mother and child.

Janine is 41 weeks pregnant, and despite labor 'going nowhere,' she experiences mild contractions. She is only 2 cm dilated which is why an IV infusion of pitocin is started, to induce or augment labor, as her contractions are infrequent and weak. Pitocin is synthetic oxytocin, which increases the frequency and strength of contractions, helping to progress labor.

The first breath of a newborn drastically changes circulatory patterns by decreasing pulmonary vascular resistance and increasing blood flow through the lungs for oxygen exchange. Fetal shunts close, and there is a transition from fetal to neonatal circulation.