A pregnant client, who is 35 weeks along, comes in for weekly fetal heart monitoring.

After 20 minutes on the monitor, the fetal heart rate tracing shows three accelerations measuring 15 beats by 15 seconds.

How should the nurse report this finding to the provider?

Rationale for Choice A:

Administering oxygen via a mask or nasal cannula is the most appropriate nursing intervention in this situation. Here's a detailed explanation:

1. Addresses Hypoxia: The client's symptoms of lightheadedness, dizziness, and tingling fingers strongly suggest hyperventilation, which can lead to hypoxemia (low blood oxygen levels). Administering oxygen directly increases the concentration of oxygen in the client's bloodstream, rapidly addressing the hypoxia and its associated symptoms.
2. Promotes Calmness: Oxygen therapy can also have a calming effect, which can help to slow the client's breathing rate and further improve oxygenation. This is crucial during the transition phase of labor, as anxiety and stress can exacerbate hyperventilation.
3. Supports Fetal Oxygenation: Ensuring adequate maternal oxygenation is essential for fetal well-being. By providing oxygen to the mother, the nurse is also indirectly supporting the oxygen supply to the fetus.

Rationale for Choice B:

Telling the client to breathe at a normal rate is not an effective intervention for hyperventilation. It's often challenging for a client experiencing hyperventilation to control their breathing rate on command. This approach can also increase anxiety, potentially worsening the hyperventilation.

Rationale for Choice C:

While notifying the physician is important to keep them informed of the client's status, it's not the immediate priority in this situation. The nurse can independently initiate oxygen therapy to address the client's hypoxia and improve her condition. The physician can then be consulted for further guidance or interventions if needed.

Rationale for Choice D:

Instructing the client to breathe into her cupped hands is a technique that can sometimes help to slow breathing and increase carbon dioxide levels. However, it's not as effective as administering oxygen in addressing the underlying hypoxia and may not provide sufficient relief for the client's symptoms.

Choice A rationale:

Misoprostol (Cytotec) is a medication used to induce labor.

It is placed in the posterior vaginal fornix.

However, it should not be used if the woman’s water has broken.

If the amniotic sac has ruptured, using Misoprostol can increase the risk of infection for both the mother and the baby.

Therefore, the statement “I can receive the Cytotec as long as my water hasn’t broken yet” indicates a need for further education.

Choice B rationale:

Walking can indeed help to speed up labor by using gravity to help the baby descend.

However, once Misoprostol has been administered, the woman is usually asked to lie on her side for about 30 to 40 minutes to allow the medication to be absorbed.

After that, if the healthcare provider agrees, she may be able to walk around.

Choice C rationale:

Monitoring the baby’s heart rate and the woman’s contraction pattern is a standard procedure during labor and delivery.

This allows the healthcare team to ensure the safety of both the mother and the baby.

It is especially important when medications like Misoprostol are used, as they can cause changes in the frequency and strength of contractions.

Choice D rationale:

Nausea and vomiting are potential side effects of Misoprostol.

However, not all women experience these side effects, and if they do occur, they are usually temporary.

The healthcare provider can offer solutions to manage these side effects if they become bothersome.