A nurse is caring for a client who had a vaginal birth 2 hours ago.
They are currently receiving Oxytocin, 20 Units in 1000 ml Lactated Ringer's solution infusing at 125 ml/hr. Which of the following findings indicates that the medication is effective?

Choice A rationale

While it is true that many narcotic pain medications are administered every four hours, this response is insufficient and potentially misleading. The duration of action of a narcotic is not the only factor to consider in the context of labor. The client's phase of labor and the potential fetal effects are also critical, particularly in the advanced stages of labor when the fetus is more susceptible to medication-induced respiratory depression.

Choice B rationale

While the nurse may need to consult the healthcare provider, this response is not the most direct or professional answer. The nurse has independent knowledge regarding the safety of medication administration based on the client's stage of labor. In the transition phase, the fetus is at a high risk for respiratory depression if narcotics are administered, and the nurse should explain this rationale directly to the client.

Choice C rationale

This response is incorrect and could be harmful. The time since the last dose is only one factor in medication administration. The transition phase of labor is characterized by rapid cervical dilation and is typically a sign that delivery is imminent. Administering a narcotic at this stage increases the risk of neonatal respiratory depression at birth, as the medication crosses the placenta and affects the fetal central nervous system.

Choice D rationale

The transition phase of labor, typically occurring when the cervix is dilated 8 to 10 cm, is a period of high risk for fetal compromise. Administering a narcotic during this phase is contraindicated because the medication can cross the placental barrier and cause neonatal respiratory depression at the time of delivery. The nurse's response should prioritize fetal safety by explaining this physiological risk, which is the most appropriate and scientific response. .

Choice A rationale

A fetal heart rate (FHR) of 110 beats per minute with moderate variability and accelerations is within the normal range (110-160 bpm). Moderate variability indicates a healthy, well-oxygenated fetus, and accelerations are reassuring signs. This client is stable and does not require immediate intervention.

Choice B rationale

A client with an epidural who is 7 cm dilated is stable. The nurse should continue to monitor the client's progress and vital signs, but there is no indication of immediate distress. The epidural can cause a slight decrease in blood pressure, which would require monitoring but not an urgent response.

Choice C rationale

A blood pressure of 110/82 mmHg, heart rate of 80 beats per minute, and oxygen saturation of 98% are all within normal ranges. This client is stable and does not have any signs of distress. The nurse should continue to monitor the client but does not need to see them first.

Choice D rationale

A fetal heart rate baseline of 130s is normal, but minimal variability and late decelerations are non-reassuring signs. Minimal variability (less than 6 beats per minute) indicates a potential lack of fetal oxygenation, while late decelerations are a sign of uteroplacental insufficiency. This requires immediate intervention.