A nurse is planning to administer misoprostol 50 mcg intravaginally for cervical ripening to a client who is at 40 weeks of gestation.

Available is misoprostol 200 mcg tablets. How many tablets should the nurse plan to administer?

Choice A rationale

Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.

Choice B rationale

Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.

Choice C rationale

While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.

Choice D rationale

Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.

Choice A rationale: Verifying that the client has signed an informed consent form is essential before initiating cervical ripening with prostaglandins. Dinoprostone insertion is an invasive procedure with potential risks such as uterine tachysystole, fetal distress, or the need for cesarean delivery. Informed consent ensures that the client understands the risks, benefits, and alternatives, and it fulfills both ethical and legal requirements. Therefore, this intervention must be included in the plan of care prior to medication administration.

Choice B rationale: Terbutaline, a beta-adrenergic agonist, must be readily available because prostaglandins can cause uterine tachysystole or hyperstimulation, which compromises uteroplacental blood flow and fetal oxygenation. Terbutaline relaxes uterine smooth muscle, reversing hyperstimulation and preventing fetal hypoxia. Having this medication immediately accessible is a critical safety measure during induction. This aligns with the provider’s order to notify for tachysystole or nonreassuring FHR and ensures rapid intervention if complications arise.

Choice C rationale: Maintaining bed rest for 2 hours after prostaglandin administration is not recommended. The correct evidence-based practice is to keep the client in a side-lying or supine position with a wedge for 30 to 60 minutes to allow absorption of the medication and reduce the risk of expulsion. Prolonged bed rest beyond this period is unnecessary and increases the risk of venous thromboembolism. Therefore, this intervention is not appropriate for the plan of care.

Choice D rationale: Dinoprostone (Cervidil, Prepidil) is a prostaglandin E2 analog that requires refrigeration to maintain stability and potency. The medication should be kept refrigerated until just before administration to ensure effectiveness. Improper storage at room temperature for extended periods can degrade the drug, reducing its efficacy in cervical ripening. Therefore, refrigeration until administration is a correct nursing intervention and should be included in the plan of care.

Choice E rationale: Assisting with an amniotomy before prostaglandin placement is not appropriate. Prostaglandins are used to ripen the cervix before oxytocin induction, and amniotomy is typically performed later to augment labor once the cervix is favorable. Performing an amniotomy prematurely increases the risk of infection, cord prolapse, and fetal distress. Since the membranes are intact and the cervix is closed and thick, prostaglandin ripening is indicated first, not amniotomy.

Choice F rationale: Keeping calcium gluconate at the bedside is necessary when administering magnesium sulfate, not prostaglandins. Calcium gluconate is the antidote for magnesium toxicity, which causes respiratory depression and cardiac complications. Since this client is not receiving magnesium sulfate, calcium gluconate is not relevant to the current plan of care. Therefore, this intervention is not appropriate in this context.

Choice G rationale: Having the client void before insertion of the prostaglandin is correct. An empty bladder reduces the risk of bladder injury during insertion, improves maternal comfort, and prevents urinary retention while the client remains in the side-lying position for 30 to 60 minutes after administration. This intervention is specifically ordered by the provider and is a standard nursing action to optimize safety and comfort during cervical ripening.