The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation (Select all that apply)?
a. Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency
b. Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency
c. Uterine tone <20 mm Hg
d. Uterine tone >20 mm Hg
e. Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and pattern
ANS: B, D, E
Uterine contractions that occur less than 2 minutes apart and last more than 90 seconds, a uterine tone of over 20 mm Hg, and a nonreassuring FHR and pattern are all indications of uterine hyperstimulation with oxytocin administration. Uterine contractions that occur more than 2 minutes apart and last less than 90 seconds are the expected goal of oxytocin induction. A uterine tone of less than 20 mm Hg is normal.
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