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?

“I will resume my normal activities as soon as possible.” This statement indicates a need for further teaching because a woman who had severe pre-eclampsia should rest more often and avoid strenuous activities until her blood pressure is normal and stable.She should also follow up with her doctor regularly and monitor her blood pressure at home.

Choice A is wrong because it is important to monitor blood pressure at home for a few weeks after having pre-eclampsia.

This can help detect any signs of worsening hypertension or organ damage.

Choice B is wrong because it is advisable to call the doctor if there are any headaches or vision changes, as these could be signs of brain injury or eclampsia.

Eclampsia is a serious complication of pre-eclampsia that causes seizures.

Choice C is wrong because some over-the-counter pain medications, such as ibuprofen, can increase blood pressure and should be avoided by women with pre-eclampsia.However, acetaminophen (Tylenol) is usually safe to take for mild pain relief.

Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg.Normal ranges for protein in urine during pregnancy are less than 300 mg in 24 hours.

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