# A 28-year-old client at 41 weeks gestation is receiving oxytocin IV for labor augmentation. The nurse notes 7 contractions in 10 minutes, contractions lasting more than 90 seconds, and late decelerations on the fetal monitor. Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375123&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 28-year-old client at 41 weeks gestation is receiving oxytocin IV for labor augmentation. The nurse notes 7 contractions in 10 minutes, contractions lasting more than 90 seconds, and late decelerations on the fetal monitor. Which is the priority nursing action?

## Option

1. Increase the oxytocin infusion to overcome the resistance and end labor faster.
2. Administer IV magnesium sulfate to slow contractions while keeping oxytocin running.
3. Stop the oxytocin infusion, reposition the client to left lateral, give 10 L/min oxygen by face mask, increase the IV maintenance fluid, and notify the prescriber; have terbutaline ready as a uterine relaxant. **✔ Correct answer**
4. Continue the current rate and document the changes.

**Correct answer: 3**

## Explanation

Oxytocin (Pitocin) is a high-alert medication used IV for labor induction and augmentation, postpartum hemorrhage, and milk letdown. The major risks are uterine tachysystole (more than 5 contractions per 10 minutes averaged over 30 minutes), hypertonus (contractions lasting more than 90 seconds or coupling), and water intoxication at high doses (oxytocin has antidiuretic activity). Tachysystole compromises placental perfusion and causes fetal hypoxia, manifesting as late decelerations or bradycardia. Standard intrauterine resuscitation: (1) stop or decrease the oxytocin infusion immediately, (2) reposition to left lateral to relieve aortocaval compression, (3) administer oxygen 8 to 10 L/min via non-rebreather mask, (4) increase the IV maintenance fluid bolus to improve placental perfusion, (5) notify the obstetric provider, (6) administer terbutaline 0.25 mg SC as a uterine relaxant if hyperstimulation persists, (7) prepare for possible operative delivery if tracing does not improve. Increasing oxytocin or continuing without intervention worsens fetal compromise. Magnesium sulfate is used for tocolysis in preterm labor, not for oxytocin-induced tachysystole; it would not replace stopping the agent.

## In-depth explanation

Stop the oxytocin first — that is always the first action when tachysystole or category III tracing appears. The mnemonic is: stop, side, oxygen, fluid, notify (SSOFN).

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