A laboring client receiving oxytocin has 6 contractions in 10 minutes averaged over 30 minutes and recurrent late decelerations. Maternal oxygen saturation is 98%. Which action should the nurse take first?
1Increase the oxytocin rate to shorten the duration of fetal exposure to labor.
2Continue the infusion and apply routine oxygen despite normal maternal saturation.
3Stop oxytocin, reposition laterally, notify the provider, and prepare further measures per protocol.✓ Correct answer
4Document the pattern and continue the current infusion until the next cervical check.
Explanation
Uterine tachysystole with recurrent late decelerations requires immediate discontinuation of oxytocin and intrauterine resuscitative measures such as lateral repositioning, prompt notification, and protocol-directed treatment. Routine oxygen is not recommended when maternal oxygen saturation is normal.
Quick answer Stop oxytocin first, reposition, and escalate.
Why this is correct Six contractions in 10 minutes averaged over 30 minutes meet the definition of tachysystole. Recurrent late decelerations show fetal intolerance, so the uterotonic stimulus must be removed immediately and the team should begin protocol-directed resuscitation.
Easy analogy or mental picture Oxytocin is pressing the contraction accelerator; release it before adding another intervention.
Memory hook Too many contractions plus late decels: stop the drip.
NCLEX decision rule Remove the iatrogenic cause first. Reposition, reassess, notify, and use additional measures such as IV fluid or a rapid-acting uterine relaxant according to the clinical protocol and orders.
Why the other choices are wrong Increasing or continuing oxytocin worsens tachysystole; routine oxygen is not indicated solely for a tracing when maternal saturation is normal.
References
1DailyMed: Oxytocin injectionImmediate discontinuation for uterine hyperactivity or fetal distress
2ACOG practice advisory mirrorNo routine oxygen when maternal oxygen saturation is normal