rationale ..seems wrong

  1. . The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to

    1. discontinue the infusion.
    2. turn client to the left side.
    3. change the fluids to LR.
    4. increase the IV flow rate.







    (1) correct-will decrease contractions and thus possibly remove uterine pressure to the fetus,
    which is possibly cause of deceleration
    (2) may help the deceleration, but is not a priority
    (3) will have no influence on the fetal heart rate
    (4) will have no influence on the fetal heart rate
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  2. 18 Comments

  3. by   Sun0408
    Why does it seem wrong to you?? Im not in OB but the baby is in distress. What is oxytocin and what are some things to look out for while administering it??
  4. by   diamond_girl
    It is right. If a baby is in distress you ALWAYS turn off the pit first.
  5. by   bhallakishu
    i thought that too it should be turn the patient first but rationale says to discontinue the infusion
  6. by   I am that I am
    You need to turn off the source of the discomfort first.
  7. by   MissyNik
    ok I didn't understand your last statement.............r u saying that the correct rationale is # and that you think it should be #1?
  8. by   MissyNik
    I will say that in Ob we were taught to always reposition first..................
  9. by   AliceTrout
    Quote from Nikkinism70s
    I will say that in Ob we were taught to always reposition first..................
    This maybe solid advice much of the time, but don't check your critical thinking at the door and automatically shoot for the positioning answer.

    Many of my NCLEX resources had a variation of this question, and your clue here is a labor dystocia and running Pitocin. Since the Pit is a likely CAUSE for the dystocia, your priority intervention is to stop it.

    Remember as you remember the reposition rule, in nursing you treat the underlying problem!
  10. by   MissyNik
    I agree AliceTrout my first idea would be to stop what may be causing the problem and see if that resolves the issue of difficult labor then try the repositioning. And Im so excited that I now get to use the other posting features...................
  11. by   Horsebytes
    Quote from Nikkinism70s
    I will say that in Ob we were taught to always reposition first..................
    Yes, I picked reposition too when I read the question.

    I know that I have found several test answers that I don't agree with while doing "nclex" questions. I also have found totally conflicting answers to similar questions in different resources. It is frustrating sometimes.
  12. by   drift54
    you can think like this: patient is being administered oxytocin (cause rapid contrac) will repositioning help the patient? (position is related to pressure on cord)
  13. by   drift54
    some are just bad questions...
  14. by   MissyNik
    yea I struggled with this in the beginning of nursing school LOL always tried to add what I thought but it took some work to get that critical thinking and stepwise prioritizing down pat.

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