A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of labor.

The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction.

What action should the nurse implement at this time?

These are normal inflammatory responses to the vaccine.

The tetanus vaccine protects people from the bacteria that cause tetanus, a serious disease that causes muscle stiffness and spasms.

The vaccine stimulates the body’s immune system to produce antibodies against the bacteria.Sometimes, this immune response can cause mild symptoms such as pain, redness, swelling, fever, headache, or tiredness.

These are not signs of an infection or an allergic reaction, but rather the body’s way of building immunity.

Choice A is wrong because an allergic reaction to the vaccine would cause more severe symptoms such as hives, swelling of the face or throat, difficulty breathing, or shock.

These symptoms would usually occur within minutes or hours of getting the vaccine and require immediate medical attention.

Choice C is wrong because these are not signs of an active infection with tetanus.

Tetanus is a rare but potentially fatal disease that causes muscle spasms and paralysis.

It is caused by bacteria that enter the body through wounds or cuts.The symptoms of tetanus usually appear several days or weeks after exposure and include lockjaw, stiffness of the neck and abdomen, difficulty swallowing, fever, sweating, and seizures.

The tetanus vaccine prevents the disease by creating immunity before exposure.

Choice D is wrong because these are not adverse effects of preservatives in the vaccine.

Preservatives are substances that prevent contamination and spoilage of vaccines.The most common preservative used in tetanus vaccines is thimerosal, a mercury-based compound that has been proven to be safe and effective.

There is no evidence that thimerosal causes autism or any other health problems.

Some people may have a sensitivity to thimerosal or other ingredients in the vaccine, but this is very rare and would cause an allergic reaction as described in choice A.

Bronchospasm.

Bronchospasm is a constriction of the airways that causes wheezing and trouble breathing.It is one of the symptoms of anaphylaxis, a severe allergic reaction that can occur within minutes of exposure to something you’re allergic to, such as a bee sting.

Choice A is wrong because bradycardia is a slow heart rate, not a fast one.Anaphylaxis causes a weak and rapid pulse due to low blood pressure.

Choice B is wrong because hypertension is high blood pressure, not low.Anaphylaxis causes blood pressure to drop suddenly and can lead to shock.

Choice D is wrong because warm, dry skin is not a sign of anaphylaxis.Anaphylaxis causes skin reactions such as hives, itching, flushed or pale skin.