A 32-year-old multigravida at 42 weeks gestation is admitted for labor induction due to post-term pregnancy. The cervix is 2 cm dilated, 60% effaced, and the fetal head is at -1 station. Which nursing intervention should be the priority before beginning oxytocin administration?
1Insert an intrauterine pressure catheter to monitor contraction strength
2Obtain a baseline fetal heart rate strip for 20-30 minutes✓ 정답
3Administer a cervical ripening agent such as misoprostol
4Place the patient in lithotomy position for cervical examination
해설
Before initiating oxytocin for labor induction, establishing a baseline fetal heart rate pattern for 20-30 minutes is essential to assess fetal well-being and provide a comparison for monitoring. Other options are incorrect because inserting an IUPC or administering cervical ripening agents are not priorities before baseline FHR assessment, and lithotomy position is for examination not a priority intervention.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action before initiating Oxytocin (Pitocin) for labor induction. The core principle is fetal safety and assessment before intervention. Before administering any medication that stimulates uterine contractions, it is imperative to establish a baseline assessment of fetal well-being. This allows the nurse to detect any pre-existing non-reassuring patterns and provides a reference point to evaluate the fetal response to the induced contractions.
Answer Rationale: Key Point! The priority is to Obtain a baseline fetal heart rate (FHR) strip for 20-30 minutes. This is a standard, evidence-based safety protocol. Oxytocin increases the frequency, duration, and intensity of uterine contractions, which can temporarily reduce blood flow to the placenta (uteroplacental perfusion). If the fetus is already compromised, induction could lead to fetal distress. A 20-30 minute baseline strip assesses the fetal heart rate variability, presence of accelerations, and absence of decelerations, confirming the fetus is in a healthy state to tolerate the stress of labor.
Distractor Analysis:
Watch out for confusion! Option 1: Inserting an Intrauterine Pressure Catheter (IUPC) is used to quantitatively measure the strength of contractions in Montevideo Units. However, this is not a priority before starting oxytocin. It may be used later if contraction patterns need closer monitoring, but the initial priority is always fetal assessment.
Option 3: Administering a cervical ripening agent like Misoprostol (Cytotec) is incorrect because the patient is already in early labor (2 cm dilated, 60% effaced). Cervical ripening agents are primarily used for an unfavorable, unripe cervix (e.g., Bishop score <6) before induction with oxytocin begins. In this scenario, the physician has ordered oxytocin induction directly.
Option 4: Placing the patient in Lithotomy position is for performing a sterile vaginal exam or other procedures. While an exam was done to determine cervical status, this is not the priority nursing intervention before starting a high-alert medication like oxytocin. The lithotomy position is also not maintained for monitoring.
Related Concepts: This integrates knowledge of the nursing process (assessment first), pharmacology (high-alert medication protocols), and obstetric nursing (principles of labor induction and fetal monitoring). Always remember the sequence: Assess (FHR baseline) → Intervene (start oxytocin) → Re-assess (FHR and contraction patterns continuously).
Concept Summary
Concept
Description
Post-term Pregnancy
Gestation extending to 42 weeks or beyond. Increases risks of macrosomia, oligohydramnios, and meconium aspiration, necessitating induction.
Oxytocin (Pitocin) Protocol
A high-alert medication. Must start with a low dose, increased gradually based on uterine response and FHR patterns. Continuous electronic fetal monitoring (EFM) is mandatory.
Baseline FHR Assessment
A 20-30 minute strip prior to induction or any intervention to establish fetal well-being (normal baseline rate, variability, accelerations).
Bishop Score
A pre-induction cervical assessment tool (dilation, effacement, station, consistency, position). A score ≥6 indicates a cervix favorable for induction.
Side-by-Side Comparison!
Intervention
Purpose & Timing
Priority Before Oxytocin?
Baseline FHR Strip (20-30 min)
Assess fetal well-being and establish a reference point.
YES - Absolute Priority
Cervical Ripening (e.g., Misoprostol)
Used when cervix is unfavorable (long, closed, firm) to prepare for induction.
No - Done before oxytocin phase if needed.
IUPC Insertion
Measures actual uterine contraction pressure in mmHg. Used if contractions are inadequate despite oxytocin.
No - An intervention during, not before, induction.
Anatomy, Physiology & Pharmacology Points
Oxytocin Mechanism: Synthetic hormone that binds to myometrial receptors, increasing intracellular calcium, which stimulates uterine smooth muscle contractions.
Fetal Physiology: Uterine contractions compress spiral arteries, temporarily reducing placental blood flow. A healthy fetus compensates via reserves; a compromised fetus may show decelerations.
Station: Describes the level of the fetal presenting part (head) in relation to the ischial spines. -1 is 1 cm above the spines (floating).
Memory Tips
ABCs for Labor & Delivery: Always think "Assess Baby First!" Before any induction or augmentation.
Oxytocin Rule: "Before you Pit, you must Sit (and monitor for 30 minutes)." (Pit = Pitocin, Sit = monitor baseline).
High-Frequency NCLEX Topics
This is a classic NCLEX question testing priority-setting and safety. The exam frequently presents scenarios with oxytocin, magnesium sulfate, or other high-risk obstetric medications. The correct answer is almost always the one involving assessment and monitoring before administration. Remember: Assessment precedes intervention.
Watch Out for Question Variations!
Symptom Recognition: "The nurse is monitoring a patient receiving oxytocin. Which finding requires immediate intervention?" (Answer: Late decelerations, uterine hyperstimulation).
Priority Intervention: "During oxytocin infusion, the FHR shows recurrent late decelerations. What should the nurse do first?" (Answer: Stop the oxytocin infusion, turn patient to left side, administer O2).
Medication Knowledge: "A patient at 41 weeks is to receive dinoprostone (Cervidil) for cervical ripening. Which nursing action is essential?" (Answer: Ensure the cervix is closed and the membranes are intact before insertion).
Nursing Clinical Practice GuideClinical Scenario: You are the labor & delivery nurse assigned to Maria, a G3P2 at 42+1 weeks. She is anxious about the induction. The physician's order reads: "Begin oxytocin IV per protocol for post-term induction." Her cervix is 2cm/60%/-1.
Nursing Intervention Strategy:
Assessment (First & Foremost): Explain the procedure to Maria. Apply the external fetal monitor (tocodynamometer for contractions, ultrasound transducer for FHR). Obtain and document a 20-30 minute baseline strip. Assess for a normal baseline FHR (110-160 bpm), moderate variability, and presence of accelerations.
Planning & Preparation: Once a reassuring baseline is confirmed, prepare the oxytocin infusion. Use an IV pump for precise control. The standard protocol is to start at a low dose (e.g., 1-2 mU/min) and increase by 1-2 mU/min every 30-60 minutes until adequate labor pattern is established (contractions every 2-3 minutes, lasting 60-90 seconds).
Implementation & Continuous Monitoring: Start the infusion. Stay with the patient during the initial 15-30 minutes of titration. Monitor FHR and contraction patterns continuously. Assess for signs of uterine hyperstimulation (contractions >5 in 10 minutes, lasting >90 seconds, or with insufficient rest between) or uterine tachysystole.
Evaluation & Patient Education: Evaluate the fetal response to each increase in dose. Educate Maria to report any severe pain, dizziness, or shortness of breath. Reassure her that close monitoring is for her and her baby's safety.
Patient Safety and Precautions:
Contraindications: Do not administer oxytocin if there is a known allergy, fetal distress, placenta previa, vasa previa, active genital herpes, or any situation where vaginal delivery is contraindicated (e.g., prior classical uterine incision).
Key Monitoring Points: FHR pattern is the primary guide. Stop the oxytocin for any non-reassuring patterns (late or variable decelerations, loss of variability) or hyperstimulation. Turn patient to left lateral position, administer O2 via non-rebreather mask, increase IV fluids, and notify the provider.
Nursing Procedure & Medication FlowOxytocin (Pitocin) IV Administration Steps:
Confirm physician's order and indication.
Obtain 20-30 min baseline FHR strip (Nursing Priority!).
Prepare solution: Typically 10 units of oxytocin in 1000 mL of isotonic IV fluid (e.g., Lactated Ringer's) = 10 mU/mL concentration.
Label the IV bag and tubing clearly "OXYTOCIN - HIGH ALERT."
Use an IV infusion pump. Prime the tubing with the oxytocin solution.
Start infusion at the ordered initial rate (e.g., 1 mU/min = 6 mL/hr with 10 mU/mL concentration).
Increase dose per protocol only after assessing FHR and contraction pattern for the previous 10-15 minutes.
Document: Baseline FHR, start time, initial rate, all rate increases, maternal and fetal responses, and any adverse reactions.
A Word from Your Senior Nurse
"Labor induction is one of the most common yet high-stakes procedures in L&D. Your role as the nurse is to be the vigilant guardian of two patients—the mother and the baby. That baseline FHR strip is your crystal ball; it tells you if the baby is ready for the journey ahead. Never rush to start the Pitocin drip. Those 20-30 minutes of assessment are non-negotiable. In the real world, this diligence prevents emergencies. On the NCLEX, it shows you understand that safe nursing is always rooted in thorough assessment before action. You've got this!"
Oxytocin — A synthetic hormone used to induce or augment labor by stimulating uterine contractions. It is a high-alert medication requiring careful titration and continuous fetal monitoring.
Fetal Heart Rate (FHR) Monitoring — The continuous or intermittent assessment of the fetal heart rate via electronic or auscultatory methods to evaluate fetal well-being during labor.
Post-term Pregnancy — A pregnancy that extends to 42 weeks (294 days) of gestation or beyond. Associated with increased perinatal risks, often necessitating labor induction.
Bishop Score — A pre-induction scoring system (0-13) assessing cervical dilation, effacement, station, consistency, and position. A higher score indicates a cervix more favorable for induction.
Uterine Hyperstimulation/Tachysystole — A complication of labor induction/augmentation characterized by excessive uterine activity: more than five contractions in 10 minutes, contractions lasting >90 seconds, or inadequate uterine relaxation between contractions.