Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center.She is lying supine on a backboard, is awake, and denies any complaints.
Her blood pressure is 80/50 mmHg and her heart rate is 130 beats/minute.
Which action should the nurse implement first?

 

Stopping oxygen per cannula after uterine hyperstimulation and subsequent contraction reduction is not appropriate. Oxygen should be continued to ensure fetal oxygenation, particularly after a period of stress caused by frequent contractions. Discontinuing oxygen too soon may compromise fetal well-being.

Choice B rationale

Checking for clonus in both feet is unrelated to the management of uterine contractions post-oxytocin administration. Clonus assessment is used in evaluating neuromuscular function, often in conditions such as preeclampsia, but not for monitoring uterine activity or response to oxytocin.

Choice C rationale

Notifying the nursery about the client's response is important for continuity of care but does not address the immediate need to manage the uterine contractions. The primary focus should be on stabilizing uterine activity before updating other departments.

Choice D rationale

Restarting the oxytocin infusion rate per protocol is the correct intervention after ensuring that the contractions have reduced to a safe frequency and duration. This approach helps to maintain labor progress while minimizing the risk of hyperstimulation and fetal distress. The nurse should follow the hospital's guidelines for oxytocin titration.

Choice B rationale

Informing the anesthesia care provider is the priority action. Ingesting coffee within a few hours before surgery can affect anesthesia management, and the anesthesia team needs to be aware of any potential complications.

Choice A rationale

Starting the IV is important but not the priority in this scenario. The anesthesia care provider needs to be informed first.

Choice C rationale

Contacting the obstetrician is also important but comes after informing the anesthesia care provider.

Choice D rationale

Ensuring preoperative lab results are available is essential, but the first step should be to inform the anesthesia care provider about the coffee intake.