An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:

A. Right occiput posterior position: This position refers to the baby's head being down but facing the mother's back, which can make labor more challenging but is not a contraindication for amniotomy.

B. -2 station: This indicates that the baby's head is not yet engaged in the pelvis. While it can complicate labor, it is not an absolute contraindication for amniotomy, though caution is advised.

C. Cephalic presentation: This is the most common and favorable position for delivery, where the baby's head is down and ready for birth. It is not a contraindication for amniotomy.

D. Dilation less than 3 cm: This is a contraindication for amniotomy because the cervix is not sufficiently dilated, which can increase the risk of complications such as infection or prolonged labor.

Choice A reason:

A prolapsed umbilical cord occurs when the cord slips ahead of the presenting fetal part, potentially leading to cord compression and compromised fetal oxygenation. However, hypertonic contractions do not directly cause a prolapsed cord. Instead, factors such as premature rupture of membranes, abnormal fetal positioning, or excessive amniotic fluid (polyhydramnios) are more likely contributors to cord prolapse. Hypertonic contractions primarily affect uteroplacental circulation rather than fetal positioning.

Choice B reason:

One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it produces a prolapsed cord. This is incorrect because a prolapsed cord is not caused by hypertonic contractions, but by other factors such as a low-lying placenta, a premature rupture of membranes, a small or preterm fetus, or an abnormal presentation. A prolapsed cord occurs when the umbilical cord slips through the cervix and into the vagina before or during delivery. This can compress the cord and cut off the blood supply to the fetus, resulting in fetal bradycardia and possible death.

Choice C reason:

One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it increases maternal renal blood flow. This is incorrect because hypertonic contractions do not affect maternal renal blood flow directly. Maternal renal blood flow is influenced by factors such as maternal blood pressure, hydration, cardiac output, and renal function. Hypertonic contractions may cause maternal dehydration, which can reduce renal blood flow, but this is not a direct effect of oxytocin stimulation.

Choice D reason:

Hypertonic contractions reduce placental blood flow by limiting the relaxation phase between contractions. Normally, uterine contractions intermittently compress the spiral arteries supplying the placenta, but prolonged or excessively frequent contractions prevent adequate placental perfusion. This can lead to fetal hypoxia, acidosis, and distress, making it the most detrimental effect of oxytocin-induced hypertonic contractions.