Question

.A nurse is caring for a GIPO client who has been in the latent phase of labor for 21 hours. Her healthcare provider plans an amniotomy followed by oxytocin administration. Which of the following nursing interventions will be necessary (Select all that apply?)

A. Monitor the client’s temperature every shift.
B. Notes the amniotic fluid characteristics
C. Assess the fetal heart rate before and after the amniotomy
D. Warm the client of the sharp pain usually experienced during this procedure
E. Help the client into a supine position after the procedure

Answer 1

Nursing interventions after an amniotomy and oxytocin administration include monitoring the patient's temperature, noting amniotic fluid characteristics, assessing fetal heart rate, describing the sensations of the procedure to the patient, and avoiding a supine position post-procedure.

Step-by-step explanation:

The question pertains to appropriate nursing interventions following an amniotomy and administration of oxytocin to a client who is in the latent phase of labor. The interventions necessary include:

• Monitoring the client's temperature every shift to watch for any signs of infection.
• Noting the characteristics of amniotic fluid during the amniotomy, such as color, odor, consistency, and any presence of meconium, which could indicate fetal distress.
• Assessing fetal heart rate before and after the amniotomy to ensure fetal well-being.
• Informing the client about sensations to expect during the procedure, though it might not be a 'sharp pain', discomfort can be expected.
• Positioning recommendations would usually be to avoid a supine position after the procedure to prevent supine hypotensive syndrome; instead, a lateral or semi-upright position is often advised.

The use of pitocin is indicated to augment or stimulate labor when progression is inadequate, such as in the scenario described where a GIPO client (gravida 1, para 0 - indicating first pregnancy and no prior births) is in extended latent labor.