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    Paediatrics and maternity proctored exam (examplify)

    The nursing is caring for a G2P1001 at 41 5/7 weeks undergoing augmentation of labor with oxytocin. Based on the monitoring strip the nurse would perform which of the following actions?

    Explanation & Rationale

    Rationale: A. Increase the oxytocin infusion: This is not appropriate if there are abnormal fetal heart rate patterns or uterine tachysystole. Increasing oxytocin would worsen fetal distress. B. Discontinue the oxytocin infusion: If the monitoring strip shows late decelerations, prolonged decelerations, bradycardia, or tachysystole (>5 contractions in 10 minutes), the priority is to stop oxytocin immediately to remove the cause of uteroplacental insufficiency or excessive uterine activity. This is the safest and most immediate nursing action. C. Prepare for vaginal delivery: Delivery is not an immediate nursing action. Preparing for delivery comes later after stabilizing the client and fetus. First priority is to resolve the problem on the strip. D. Continue to monitor contraction duration every 2 hours: This is unsafe if there are abnormal findings. Fetal distress requires immediate intervention, not delayed reassessment.

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