rationale ..seems wrong

Nursing Students NCLEX

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. 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

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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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
i thought that too it should be turn the patient first but rationale says to discontinue the infusion

If the patient is on Pit and there are prolonged decells that baby isn't tolerating the PIT induced labor STOP THE OFFENSIVE med first'

If this all started with the med stop the med

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If you could only do one thing for this patient and then leave, what would you do? Turn off the pit!

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I actually just read this chapter in my Pillitterri book! A dangerous side effect of Oxytocin is hyperstimulation of the uterus. Hyperstimulation of the uterus leads to fetal distress because the uterus does not have a chance to relax and deliver oxygen to the fetus. Pilliterri says, and I quote, "If signs of fetal distress occur (in this case, prolonged decels) stop the IV infusion and seek help immediately."

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thnxs guys for the explanation.........aquamoon thanxs for explaining it in detail

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Specializes in BMT.

The thing to remember with NCLEX... sometimes a) the answer you want (the actual 1st intervention you should do) might not be there, and b) you might ACTUALLY do two, three, or all of the things listed, BUT the question is, of the interventions provided, which one would you do FIRST? Which one is the MOST right?

I'm no OB nurse, but here's how I looked at the question: I replaced "oxytocin" with "any IV medication" and "decelerations" with "adverse reaction". The FIRST thing you ALWAYS do when you have an adverse reaction during an IV infusion is STOP the infusion, THEN proceed to your other interventions to alleviate said adverse reaction. Remember, NCLEX is asking you, what is the MOST right, RIGHT NOW?

My breakthrough in nursing school was when my professor put it to me this way "what will kill my patient faster?" You'll almost always be lead in the right direction if you ask yourself that. Hope that helps explain the rationale a little better.

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I picked reposition also .... after reviewing the answer though; turning off the infusion makes better sense. My critical thinking got me to this.... KEY WORD Prolong deceleration- baby is in distress and being deprived of oxygen. I know that with each uterine contraction the umbilical cord is " clamping down"

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