A pregnant woman is admitted with first stage of labour receiving 10 -unit Oxytocin in IV fluid with cervical dilation 3 cm and she has a contraction of 70 seconds every 3-5 minutes. What would be the priority nursing intervention?

1. A

   Check FHR

2. B

   Notify the physician

3. C

   Turn off the IV Oxytocin

4. D

   Prepare for delivery because she is probably in transition phase

Appeared in: NORCET 3 - 2022 (Shift-1)

Explanation

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• A contraction duration of 70 seconds is a sign of uterine hyperstimulation (tachysystole), a common adverse effect of oxytocin administration.
• Prolonged contractions (typically defined as lasting longer than 60-90 seconds) reduce the resting interval between them, which can impair blood flow to the placenta and lead to fetal hypoxia.
• The immediate priority is to stop the causative agent—the oxytocin infusion—to allow the uterus to relax and restore adequate placental perfusion, thereby protecting the fetus.
• This is a critical, independent nursing action that must be taken before other steps like notifying the provider.

Why Other Options Were Wrong

• Option A: While checking the Fetal Heart Rate (FHR) is a vital assessment, it does not solve the underlying problem of uterine hyperstimulation. The priority is to take corrective action first.
• Option B: Notifying the physician is a necessary step but not the first priority. The nurse must take immediate action to ensure patient safety before reporting the situation.
• Option D: This statement is factually incorrect. A cervical dilation of 3 cm is characteristic of the active phase of the first stage of labor, not the transition phase (which occurs at 8-10 cm).

Related Visual

• Visual 1: Fetal Monitor Strip - A strip showing uterine tachysystole (contractions lasting over 60-90 seconds and occurring too frequently) to help learners recognize the pattern.
• Visual 2: Flowchart - A flowchart outlining the step-by-step nursing management of uterine hyperstimulation, starting with stopping the oxytocin infusion, followed by repositioning, IV fluids, oxygen, and notifying the provider.

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Management of Oxytocin-Induced Uterine Tachysystole in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Oxytocin is a high-alert medication requiring continuous maternal and fetal monitoring. Nurses must be able to recognize signs of uterine hyperstimulation and act immediately to prevent adverse outcomes.
• The nurse's priority is always patient safety. In this case, stopping the infusion is a critical, independent nursing action to prevent potential harm to the fetus.
• What if? If stopping the oxytocin and repositioning the mother does not resolve the tachysystole and a non-reassuring fetal heart rate pattern develops, the nurse should be prepared to administer a tocolytic agent (like terbutaline) as per standing orders or a physician's order to relax the uterus.

How to Approach the Question

• Identify the clinical scenario: A pregnant woman in labor is receiving an oxytocin infusion.
• Analyze the data provided: Note the cervical dilation (3 cm) and the contraction pattern (70 seconds long).
• Recognize the abnormality: A contraction duration of 70 seconds is prolonged and indicates uterine hyperstimulation (tachysystole), a known risk of oxytocin.
• Prioritize interventions: The question asks for the priority action. In a situation where a medication is causing an adverse effect, the first step is always to stop that medication.
• Evaluate the options based on this principle: 'Turn off the IV Oxytocin' directly addresses the cause of the problem. 'Check FHR' and 'Notify the physician' are subsequent or concurrent actions. 'Prepare for delivery' is incorrect based on the clinical data.

Concept Tested & Keywords

• Concept Tested: Management of Oxytocin-Induced Uterine Tachysystole
• Stem keywords: first stage of labour, Oxytocin, cervical dilation 3 cm, contraction of 70 seconds
• Lead-in keywords: priority nursing intervention
• Clinical cues: Contraction duration of 70 seconds is the key abnormal finding, indicating uterine hyperstimulation.

Question ID

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