A woman is receiving oxytocin (Pitocin) via infusion. The nurse assesses the following: uterine contractions lasting 100 seconds every 1.5 minutes, uterine resting tone 36 mm Hg, baseline fetal heart rate (FHR) 108 beats/minute with absent variability
What action by the nurse takes priority?
A.
Document the findings.
B.
Notify the provider.
C.
Reassess the FHR in 10 minutes
D.
Stop the infusion.
ANS: D
Oxytocin can cause uterine tachysystole, and the nurse's assessments are consistent with this condition. The priority action by the nurse is to stop the infusion. The nurse should notify the provider. Documentation should be thorough. Reassessment should be driven by a written protocol.
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