A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

A. Resting tone of 15 mmHg:A resting tone of 15 mmHg is generally acceptable and indicates normal uterine resting pressure, which should be between 5 and 20 mmHg.

B. Frequency of every two minutes. A frequency of every two minutes can be acceptable during labor, especially if the contractions are not too long or intense. The key consideration is the duration and intensity of the contractions.

C. Intensity of 60 to 90 mmHg: This intensity is typically acceptable for labor induction and signifies effective contractions. There’s no indication to stop oxytocin based solely on this intensity range.

D. Duration of 90 to 120 seconds:A contraction lasting 90 to 120 seconds is concerning and indicates potential uterine hyperstimulation, warranting the discontinuation of oxytocin to protect both the mother and fetus from adverse effects.

A. Helping the client to the bathroom to void is not the priority in this situation. The urge to push could indicate that the baby is descending, and the nurse should be prepared for imminent delivery.

B. Observing the perineum for signs of crowning is a valid action, but having the client pant during contractions is more appropriate at this stage. It can help prevent rapid descent and potential trauma if delivery is imminent.

C. Having the client pant during the next contractions is the correct action.

Panting during contractions may slow down the urge to push and prevent rapid delivery, especially if the healthcare provider is not present or the delivery is not imminent.

D. Assisting the client into a comfortable position is important, but the priority is to manage the urge to push. Panting can be an effective technique for delaying pushing until the healthcare provider is ready for the delivery.