Pestano, Gia Selena L.

April 15, 2020

BSN 2y2 – 2 NCMA 219 LEC
A woman is having term labor induced with oxytocin. Her cervix is 4 cm dilated and fully
effaced and the fetal head is at station 0. The nurse notes that the FHR is near its baseline of 120
to 130 bpm, with a variability of 10 bpm. Contractions are firm and occur every 2 minutes (every
120 seconds), and the duration is usually 100 seconds. The nurse must palpate contractions
because the woman has thick abdominal fat. With palpation, the nurse notes that the woman's
uterus dos not fully relax before another contraction begins.
1. What is the correct interpretation of these assessments?
The patient has clinical manifestations of Tachysystole.
2. What are appropriate nursing actions in this situation, and why are they done?
Her baseline. Her temperature is checked every 4 hours (every 2 hours after membrane
rupture) to identify infection.
Recording intake and output identifies fluid retention, which precedes water water
intoxication. Signs and symptoms of water intoxication include headache, blurred vision,
behavioural changes, increased blood pressure and respirations, decreased pulse, rates, wheezing,
and coughing.
After Birth, observe for postpartum haemorrhage caused by uterine relaxation,
Postpartum uterine atony is more likely if the woman has received oxytocin for a long time
because the uterine muscle becomes fatigued and does not contract effectively to compress
vessels at the placental site. It is manifested by a soft uterine fundus and excess amounts of
lochia, usually with large clots. Hypovolemic shock may occur with haemorrhage.
 Reduce or stop oxytocin infusion.
 Increase the rate of the primary nonadditive infusion.
 Keep the labouring woman in a lateral position.
 Give oxygen by snug face mask, 8 to 10 L/min.
 Notify the physician or nurse midwife.