A nurse is caring for a client who is in labor and receiving oxytocin. The electronic fetal monitor indicates contractions every 50 seconds, lasting 2 min and late decelerations. Which of the following actions should the nurse take?

Rationale:

A. Dietary intake: The client ate 75% of breakfast, which indicates adequate oral intake. While monitoring nutrition is important in schizophrenia, this finding does not pose an immediate safety concern or require urgent reporting.

B. Sore throat: A sore throat in a client taking clozapine is significant because clozapine can cause agranulocytosis, a potentially life-threatening reduction in white blood cells. Any signs of infection, such as sore throat or fever, must be reported immediately to prevent serious complications.

C. Heart rate: A heart rate of 98/min is slightly elevated but within acceptable limits for many adults. This finding alone does not indicate an urgent issue requiring immediate provider notification.

D. Blood pressure: A blood pressure of 102/56 mm Hg is slightly low but may be within the client’s normal range, particularly if the client experiences dizziness when changing positions. While it should be monitored, it does not require urgent reporting unless symptoms worsen.

Rationale:

A. Slow down the oxytocin infusion: Contractions occurring every 50 seconds and lasting 2 minutes indicate severe uterine hyperstimulation, which reduces placental blood flow and contributes to late decelerations. Slowing or stopping the oxytocin helps decrease contraction intensity and frequency, improving fetal oxygenation.

B. Administer oxygen at 2 L/min per nasal cannula: Oxygen administration can support fetal oxygenation, but 2 L/min via nasal cannula delivers minimal benefit in an acute distress situation. Oxygen would be used as a supportive measure after correcting the cause of the late decelerations. The first action is reducing uterine activity by adjusting the oxytocin infusion.

C. Place the client in a lithotomy position for delivery: Lithotomy positioning is used during the second stage of labor but is inappropriate when the fetus shows signs of distress. It does not relieve uterine hyperstimulation or improve placental blood flow. Positioning that enhances perfusion, such as side-lying, would be more beneficial after reducing the oxytocin.

D. Increase the rate of IV fluid infusion of lactated Ringers: Increasing IV fluids may help improve maternal circulation, but it does not directly resolve contractions that are too frequent or prolonged. Fluids can be an adjunct intervention but should not occur before decreasing oxytocin in the presence of late decelerations.