QUESTION: "The physician orders an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida with class B insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. Which of the following would the nurse do before starting the oxytocin induction?"
CHOICES
( X ) a.) Administer a 500 mL bolus of intravenous fluid to prevent hypotension.
( O ) b.) Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes.
( X ) c.) Insert an indwelling urinary catheter to determine intake and output accurately.
( X ) d.) Call the anesthesiologist to begin administration of epidural anesthesia.
RATIONALE: Induction of labor with an oxytocic agent carries risks, such as water intoxication and uterine rupture. Before beginning intravenous oxytocin infusion, the nurse should obtain a baseline measurement of fetal heart rate and assess the client's contractions. If the fetal heart rate pattern shows fetal distress, the client is not a candidate for induction. This monitoring continues throughout the duration of therapy. The infusion should be discontinued and the physician notified if fetal distress is noted or if contractions occur less than 2 minutes apart or last longer than 60 seconds. A bolus of intravenous fluid is not necessary because of the possibility for fluid overload and intoxication. It is not necessary for an indwelling catheter to be inserted as long as the client is able to void and the nurse maintains a strict record of intake and output. Inserting a catheter also would predispose the client to a possible urinary tract infection. Because the client's cervix is only 1 cm dilated, it is too early for epidural anesthesia.
It is not necessary to administer a bolus of intravenous fluid, nor is it necessary for the client to have a Foley catheter at this time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
