A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving Oxytocin. The nurse's first intervention should be to?

1. A

   Check FHT

2. B

   Notify the attending physician

3. C

   Turn off the IV oxytocin

4. D

   Prepare for the delivery because the client is probably in transition

Appeared in: NORCET 5 mains

Explanation

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• The patient is exhibiting signs of uterine hyperstimulation (tachysystole), a known adverse effect of oxytocin, indicated by a contraction lasting 70 seconds.
• Prolonged contractions can decrease uteroplacental blood flow, leading to fetal hypoxia and distress.
• The immediate priority is to remove the cause of the hyperstimulation. Stopping the oxytocin infusion is the fastest and most direct way to reduce uterine activity and prevent harm to the fetus.
• According to safety protocols, if contractions last longer than 1 minute or are too frequent, the oxytocin infusion must be stopped immediately.

Why Other Options Were Wrong

• Option A: While checking the fetal heart tones (FHT) is a critical assessment, it is not the first intervention. The primary goal is to first stop the action that is causing potential fetal distress.
• Option B: Notifying the physician is a necessary step but is not the first priority. The nurse must take immediate action to stabilize the patient and prevent harm before making a call.
• Option D: The client is only 3 cm dilated, which is considered the active phase of labor, not the transition phase (which is typically 8-10 cm). A prolonged contraction is a complication, not a sign of rapid labor progression.

Related Visual

• Visual 1: Infographic: Step-by-step guide for managing uterine tachysystole during labor, showing the sequence of stopping oxytocin, repositioning, giving oxygen, and notifying the provider.
• Visual 2: Chart: A visual comparison of normal uterine contraction patterns (duration, frequency, intensity) versus tachysystole.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing interventions for oxytocin-induced uterine hyperstimulation (tachysystole) to guide bedside assessment, documentation, and the next nursing action.
• This scenario highlights a critical patient safety responsibility for nurses managing labor inductions. Prompt recognition and management of oxytocin-induced tachysystole are essential to prevent fetal distress, uterine rupture, and other adverse outcomes.
• Nurses must be empowered to act autonomously in this emergency situation by stopping the infusion before notifying the provider, as per established protocols.
• What if the contraction lasted 55 seconds and the FHR was reassuring? In this case, the nurse would continue to monitor the patient closely, as a 55-second contraction is within the normal range for active labor. The oxytocin would not need to be stopped.

How to Approach the Question

• First, identify the question type. This is a priority-setting question asking for the 'first' nursing intervention.
• Analyze the clinical data provided: The patient is receiving Oxytocin, and the key abnormal finding is a contraction lasting 70 seconds.
• Recognize this abnormal finding as a sign of uterine hyperstimulation (tachysystole), a known complication of Oxytocin.
• Apply the nursing principle of 'address the cause first.' The cause of the hyperstimulation is the Oxytocin.
• Evaluate the options based on this principle. Stopping the Oxytocin (Option C) is the only choice that directly removes the cause of the problem.
• Rule out the other options as secondary actions. Checking FHT (A) and notifying the physician (B) are important but come after the immediate safety intervention. Preparing for delivery (D) is incorrect based on the patient's cervical dilation.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing interventions for oxytocin-induced uterine hyperstimulation (tachysystole).
• Stem keywords: induction of labor, 42 weeks gestation, Oxytocin, contraction of 70 seconds, 3 cm dilated
• Lead-in keywords: first intervention
• Clinical cues: A contraction duration of 70 seconds is a critical cue for uterine hyperstimulation, as normal contractions in active labor typically last 40-60 seconds.

Question ID

QKdwuUDAXyqMR0S0HyRpLn

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