A nurse is assessing a newborn immediately following a vaginal birth.
For which of the following findings should the nurse intervene?

Choice A rationale

Palpating contractions as mild indicates that the current oxytocin dose is likely insufficient to achieve an expected labor pattern. Oxytocin aims to induce moderate-to-strong uterine contractions, typically occurring every 2-3 minutes, lasting 40-90 seconds. Mild contractions suggest suboptimal uterine activity, justifying an increase in the infusion rate to stimulate more effective contractions.

Choice B rationale

Spontaneous rupture of membranes is a natural progression of labor and does not directly indicate the need to titrate oxytocin based on uterine contraction effectiveness. While rupture of membranes can accelerate labor, the oxytocin titration decisions are primarily based on the intensity and frequency of uterine contractions, not the status of the amniotic sac.

Choice C rationale

A decrease in the client's pain level is not an indicator for titrating oxytocin for labor induction. Pain is subjective and influenced by various factors, including analgesia. Oxytocin titration is guided by objective measures of uterine activity and cervical change, aiming for an adequate labor pattern rather than pain management.

Choice D rationale

Stabilization of the client's blood pressure, while desirable, is not a direct parameter for titrating oxytocin to achieve an expected labor pattern. Oxytocin's primary effect is on uterine contractility, and titration decisions are based on the frequency, duration, and intensity of contractions, and cervical dilation, not systemic blood pressure changes.

The client is at risk for developing Intraamniotic infection as evidenced by White blood cell count.

Rationale for correct answers:
Intraamniotic infection (chorioamnionitis) is a bacterial infection of the amniotic sac often associated with prolonged rupture of membranes and labor. This client has spontaneous rupture of membranes (SROM) 1 hour ago with positive nitrazine test confirming amniotic fluid presence. The elevated white blood cell count (19,800/mm³; normal 5,000–15,000/mm³) is an early marker of infection or inflammation. The presence of group B streptococcus further increases infection risk. The amniotic fluid is moderate and clear, which is normal, so fluid characteristics alone do not indicate infection. Early identification and management of intraamniotic infection are critical to prevent maternal and fetal morbidity.

Rationale for incorrect Response 1 options:
Fetal hypoxia typically manifests as abnormal fetal heart rate patterns such as late decelerations or decreased variability, which are not present here (FHR 150/min, moderate variability). Labor dystocia refers to abnormal or slow labor progress; with 2 cm dilation and regular contractions, no evidence suggests dystocia yet. Gestational hypertension is a maternal hypertensive disorder unrelated to current rupture or WBC findings.

Rationale for incorrect Response 2 options:
Amniotic fluid characteristics (clear, moderate) are normal and not indicative of infection. Uterine tone is moderate and normal on palpation, not suggesting infection or abnormal labor. Cervical exam findings (2 cm dilation, 10% effacement) are early labor signs but do not indicate infection risk.

Take home points:

• Elevated WBC after rupture of membranes signals increased risk of intraamniotic infection.
• Clear amniotic fluid with positive nitrazine confirms membrane rupture but does not confirm infection.
• Early labor signs should be monitored for infection risk, especially with group B strep positive status.
• Differentiating infection from other labor complications like dystocia or fetal hypoxia relies on clinical signs and fetal monitoring.