A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

The correct answer is B. Turn the client onto her side.

A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.

B. Turning the client onto her side is the correct first action.

Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.

C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.

D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.

The correct answer is A. Blood pressure 80/56 mm Hg.

A. A blood pressure of 80/56 mm Hg is the priority finding. Opioid analgesia can cause hypotension, and addressing low blood pressure is crucial to prevent maternal and fetal complications. The nurse should notify the healthcare provider promptly and implement interventions to improve blood pressure.

B. Profuse itching is a common side effect of opioids and is generally not considered a priority unless it becomes severe or is accompanied by other concerning symptoms.

C. A temperature of 38.2°C (100.8°F) may indicate a fever, but addressing hypotension takes precedence. Elevated temperature can be further assessed but is not the priority in this scenario.

D. The client reporting weakness of the lower extremities is a concerning symptom, but the priority is to address hypotension first, as it could be related to opioid-induced hypotension.