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More questions ( 14 Questions)
A nurse is caring for a client who is undergoing an oxytocin-stimulated contraction stress test (CST).
The nurse observes three contractions in 10 minutes with no late decelerations of the fetal heart rate (FHR).
Which of the following actions should the nurse take?
Discontinuing oxytocin infusion and monitoring the client for another 10 minutes will not provide enough information about the fetal response to contractions. The test requires at least three contractions in 10 minutes to be valid.
Increasing oxytocin infusion and monitoring the client until four contractions occur in 10 minutes may cause uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress.
Stopping oxytocin infusion and notifying the provider of a positive CST result is not appropriate. A positive CST result means that there are late decelerations of the FHR after more than half of the contractions, indicating fetal hypoxia and placental insufficiency.
In this case, there are no late decelerations, so the test result is not positive.
Maintain oxytocin infusion and monitor the client until a negative CST result is confirmed.
A negative CST result means that there are no late decelerations of the FHR after three contractions in 10 minutes. This indicates that the fetus can tolerate the stress of labor and has adequate oxygenation.
Maintain oxytocin infusion and monitor the client until a negative CST result is confirmed.
A negative CST result means that there are no late decelerations of the FHR after three contractions in 10 minutes. This indicates that the fetus can tolerate the stress of labor and has adequate oxygenation.
Choice A is wrong because discontinuing oxytocin infusion and monitoring the client for another 10 minutes will not provide enough information about the fetal response to contractions. The test requires at least three contractions in 10 minutes to be valid.
Choice B is wrong because increasing oxytocin infusion and monitoring the client until four contractions occur in 10 minutes may cause uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress.
Choice C is wrong because stopping oxytocin infusion and notifying the provider of a positive CST result is not appropriate. A positive CST result means that there are late decelerations of the FHR after more than half of the contractions, indicating fetal hypoxia and placental insufficiency.
In this case, there are no late decelerations, so the test result is not positive.