When the client receiving an oxytocin (Pitocin) drip at 16 mU/min develops hypertonic stimulation, FHR 138 bpm with accelerations, and no decelerations, the nurse's best response would be to:
a. stop the drip immediately.
b. decrease the dose to 14 mU/min.
c. reassess the patient at 5 minute intervals.
d. reposition the patient to the left side-lying position.
ANS: B
In the absence of any adverse fetal response, hypertonic stimulation can be managed by reducing the infusion rate by 1 to 2 mU/min until uterine hyperstimulation is resolved. Stopping the drip immediately is not necessary unless hyperstimulation continues and adverse fetal responses occur. Reassessing and repositioning are of no benefit in this situation.
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