Maternity Nursing Q 25
While the client is in active labor with twins and the cervix is 5 cm dilated, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?
A. Note the fetal heart rate patterns.
B. Notify the physician immediately.
C. Administer oxygen at 6 liters by mask.
D. Have the client pant-blow during the contractions.
Correct Answer: B. Notify the physician immediately.
The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.
Option A: A baby’s heart rate during labor should be between 110 and 160 beats per minute, but it may fluctuate above and below this rate for a variety of reasons.
Option C: Maternal oxygen is often given to laboring women to improve fetal metabolic status or in an attempt to alleviate non-reassuring fetal heart rate patterns. However, there are only two randomized trials investigating the use of maternal oxygen supplementation in laboring women. These studies did not find that supplementation is likely to benefit the fetus and may even be harmful.
Option D: During active labor, breathing should be as slow as possible, but it can be sped up as the intensity of the contraction increases. As the contraction peaks and the breathing rate increases, switch to light breathing both in and out the mouth, about one breath per second.