Question

Ten minutes after administering nalbuphine (Nubain) via IV piggyback to a primigravida in active labor, the nurse observes a fetal heart rate of 132 with minimal variability. The client states that the pain is more tolerable and she is able to use her breathing techniques more effectively. Contractions continue every 2 to 3 minutes and are of 60 seconds' duration. What is the nurse's next action?

A. Reposition the client on the left side to increase placental perfusion
B. Administer oxygen via mask to minimize apparent fetal compromise
C. Have an opioid antagonist available to be administered to the infant at the time of birth
D. Document the findings, including the decreased fetal heart rate variability as a result of the opioid infusion

Answer 1

The nurse should document the findings, as decreased fetal heart rate variability can be an expected result of opioid infusion and the other signs indicate that labor is progressing normally.

Step-by-step explanation:

The nurse's next action after observing a fetal heart rate of 132 with minimal variability, 10 minutes after administering nalbuphine (Nubain) via IV piggyback to a primigravida in active labor, should be D. Document the findings, including the decreased fetal heart rate variability as a result of the opioid infusion. It is expected that the administration of opioids can lead to a reduction in fetal heart rate variability without necessarily indicating fetal distress, provided the overall heart rate is within the normal range, which is typically 110 to 160 beats per minute. Furthermore, the client's report that pain is more tolerable, and the use of breathing techniques are more effective, along with the continuation of regular contractions, suggest that the labor is progressing satisfactorily and that there is not an immediate concern requiring intervention such as repositioning or administering oxygen.