Question

The laboring client is experiencing contractions every \(2-3\) minutes lasting 90 seconds. The client's fetal heart rate is ranging from 130 to 140 beats per minute (BPM) with variability of \(6 \mathrm{p}-10\) beats per minute. Which action by the nurse is most appropriate? A. Discontinue the IV fluid containing Pitocin (oxytocin) B. Document the finding in the client's medical record C. Contact the doctor at once and reposition the client D. Insert an internal fetal scalp electrode monitor

Short answer

Answer: The most appropriate action for the nurse to take is to document the finding in the client's medical record.

Step-by-step solution

Analyze the given data

We are given the following information about the client: - Contractions every 2-3 minutes - Contractions lasting 90 seconds - Fetal heart rate (FHR) at 130-140 beats per minute (BPM) - Variability of 6-10 BPM

Evaluate the contractions

During labor, contractions are expected to occur at regular intervals and increase in intensity, frequency, and duration. In this case, contractions every 2-3 minutes lasting 90 seconds are normal for the active phase of labor.

Evaluate the fetal heart rate and variability

A normal FHR is between 110 and 160 BPM, so the client's FHR of 130-140 BPM falls within the normal range. FHR variability measures the fluctuations in FHR and is an important indicator of fetal well-being. Normal FHR variability is between 6 and 25 BPM; therefore, the given variability of 6-10 BPM is considered normal.

Assess the given actions and determine the most appropriate one

Review the potential actions and determine which one is the most appropriate: A. Discontinuing the IV fluid containing Pitocin (oxytocin) would not be appropriate, as the contractions and FHR are within normal limits, and there is no indication of fetal distress or hyperstimulation. B. Documenting the findings in the client's medical record is appropriate, as the contractions and FHR are within normal limits, and there are no issues to report. C. Contacting the doctor and repositioning the client would only be necessary if there were signs of fetal distress, which there are none. D. Inserting an internal fetal scalp electrode monitor is an invasive procedure and should only be done if there are concerns about the accuracy of external monitoring, which there are not in this case.

Choose the most appropriate action

Based on the analysis of the given data and actions, the most appropriate action for the nurse to take would be: B. Document the finding in the client's medical record.