A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin.

The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds.

The fetal heart rate is 160 beats/minute with late decelerations.

What is the priority nursing action?

The correct answer is d. Notify the health care provider.

Rationale for Choice A:

• Increasing the rate of oxytocin infusion is contraindicated in this situation.
• Oxytocin stimulates uterine contractions, and the client is already experiencing excessively frequent and prolonged contractions.
• Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
• It could also put the client at higher risk for uterine rupture, a serious complication associated with oxytocin use.

Rationale for Choice B:

• While administering oxygen is a common intervention for fetal distress, it's not the priority action in this case.
• Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency, which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
• Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.

Rationale for Choice C:

• Turning the client to her left side is a recommended position to improve placental blood flow.
• However, in this situation, it's not the priority action given the presence of late decelerations and excessive uterine contractions.
• It may be a helpful adjunct measure, but it won't address the primary cause of fetal distress.

Rationale for Choice D:

• Notifying the health care provider is the most crucial action because:
  • The client has severe pre-eclampsia, a serious condition that requires close monitoring and management.
  • The frequent and prolonged contractions, along with late decelerations in the fetal heart rate, indicate potential fetal distress.
  • The health care provider needs to be aware of these changes to make timely decisions regarding interventions, such as:
    • Adjusting the oxytocin infusion
    • Expediting delivery if necessary
    • Implementing other measures to improve fetal well-being
    • Closely monitoring the mother's condition to prevent complications of pre-eclampsia