Maternity Nursing: Intrapartum Q 1
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?
A. Three contractions occurring within a 10-minute period
B. Increased urinary output
C. Adequate resting tone of the uterus palpated between contractions
D. A fetal heart rate of 90 beats per minute
Correct Answer: D. A fetal heart rate of 90 beats per minute
A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue Pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.
Option A: Pitocin (oxytocin injection) is a natural hormone that causes the uterus to contract used to induce labor, strengthen labor contractions during childbirth, control bleeding after childbirth, or induce an abortion.
Option B: Oxytocin has an antidiuretic effect and increases the urinary excretion of AQP2 in humans whose urinary concentration mechanism is preserved. Urine volume and free water clearance were decreased, and urine osmolality was increased by the administration of oxytocin or dDAVP in the normal volunteers and CDI patients.
Option C: In a normal labor, one contraction every two to three minutes or less than five contractions in a 10 minute period is ideal. A uterus must rest between contractions, having sufficient uterine resting tone (soft to the touch), and uterine resting time (about one minute).