MEDizzy - A client is admitted to the birthing unit in active labor.

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Nursing Care of Women at Risk During Pregnancy & Post-partum

A client is admitted to the birthing unit in active labor. Cervical dilation has progressed from 2 to 3 cm during an 8-hour period. The health care provider determines that she has hypotonic dystocia, and an infusion of oxytocin (Pitocin) is prescribed to augment her contractions. What is the most important nursing action at this time?

ExplanationD. Oxytocin (Pitocin) increases the intensity and duration of contractions; prolonged (tetanic) contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug. A. A bulging perineum indicates that there is complete cervical dilation and birth is imminent; because cervical dilation is only 2 to 3 cm, a bulging perineum is not expected. B. This is important throughout labor. C. There is no indication at this time that a cesarean birth is necessary.