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Administering an IV fluid bolus may be helpful in preventing hypotension or maintaining hydration, but it is not the most critical action before oxytocin induction. Oxytocin can cause uterine tachysystole and fetal distress, so fluid bolus alone does not address the primary risk.

Inserting a urinary catheter can help monitor urine output and bladder distension, but it is not essential before starting oxytocin. Catheterization is more relevant in surgical or anesthesia contexts rather than induction safety.

Performing glucose monitoring is important in diabetic clients, but it is not universally required before oxytocin induction. Oxytocin does not directly alter glucose metabolism, so this is not the priority action.

An increase in blood pressure is not a direct indicator of oxytocin’s effectiveness. Blood pressure changes may occur due to fluid shifts or vasoconstriction, but they do not confirm control of hemorrhage.

An increase in lochia rubra would actually suggest worsening bleeding rather than improvement. Oxytocin should reduce blood loss by contracting the uterus, not increase it.

Relief of afterpains is subjective and not a reliable measure of oxytocin’s effectiveness. Oxytocin often increases afterpains due to uterine contractions, so this is not a valid indicator.

Administering the highest effective dose is unsafe. Oxytocin must be titrated carefully because excessive dosing can cause uterine tachysystole, fetal distress, or uterine rupture.

Intermittent monitoring is not appropriate with oxytocin infusion. Continuous monitoring is required because oxytocin increases risk of fetal compromise and uterine hyperstimulation.

Discontinuing oxytocin for reassuring fetal heart patterns is incorrect. Oxytocin should be discontinued if fetal heart patterns become non-reassuring or if uterine tachysystole occurs, not when patterns are reassuring.

The prone position is not recommended in pregnancy. It does not improve uteroplacental blood flow and is impractical for a laboring client.

The Trendelenburg position is not appropriate. It increases maternal discomfort, does not improve placental perfusion, and may worsen respiratory compromise.

The supine position is contraindicated in pregnancy because the uterus compresses the inferior vena cava, reducing venous return and cardiac output. This decreases uteroplacental blood flow and worsens fetal oxygenation.

This statement is accurate. Continuous monitoring of fetal heart rate and uterine contractions is a standard safety measure during oxytocin induction. It ensures early detection of fetal distress or uterine hyperstimulation, allowing timely intervention.

This statement is correct. Once adequate labor is established, oxytocin can often be reduced or discontinued to prevent overstimulation while maintaining effective contractions. This practice minimizes risks such as uterine rupture or fetal compromise.

This statement is also correct. Oxytocin increases uterine contractility, leading to stronger and more frequent contractions. This is expected and desired during induction, provided contractions remain within safe parameters.

A reassuring fetal heart tracing indicates normal fetal oxygenation and wellbeing. This is not a concern and requires no immediate intervention.

Contractions occurring every 4 minutes are within normal labor progression. This is not concerning unless accompanied by abnormal fetal heart patterns or maternal distress.

A pink mucus plug is a normal sign of cervical change and impending labor. It is expected and not a cause for concern.

Continuing to monitor without intervention is not appropriate because the client has had no cervical change over 2 hours, indicating ineffective labor. Intervention is needed to augment contractions.

Performing another vaginal exam alone will not address the lack of progress. Vaginal exams are useful for assessment but do not stimulate labor.

Administering an enema is outdated and not recommended for labor augmentation. It does not promote cervical change and may cause discomfort.

Contractions that stop with comfort measures such as rest, hydration, or position change are characteristic of false labor. They do not indicate true labor.

Rupture of membranes can occur in both true and false labor. While it may signal impending delivery, it is not by itself diagnostic of true labor.

The station of the presenting part indicates fetal descent but does not confirm true labor. Descent can occur without cervical change, so it is not the defining feature of true labor.

Intermittent fetal heart auscultation is appropriate when contractions are infrequent and the fetal heart rate is reassuring. It allows monitoring without continuous electronic fetal monitoring, especially in low-risk cases.

Nipple stimulation is a natural method to promote uterine contractions by stimulating endogenous oxytocin release. However, in this case, contractions are already present, and nipple stimulation is not contraindicated.

Administration of IV fluids is safe and often necessary to maintain hydration, support uteroplacental perfusion, and prevent maternal hypotension.

Fetal scalp stimulation is used to assess fetal responsiveness when variability is minimal. It is not appropriate as an initial intervention in the presence of tachysystole and prolonged decelerations.

Applying oxygen can improve maternal oxygenation and fetal oxygen delivery, but it is not the first step when uterine hyperstimulation is present.

Administering an IV bolus may help improve uteroplacental perfusion, but it is secondary to stopping the source of overstimulation (Pitocin).