A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply.

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Oxytocin is a high-alert medication commonly used for labor induction or augmentation. It should be administered via an electronic infusion pump (Option D), which decreases medication errors, provides for accurate dosing, and prevents maternal hypotension associated with rapid oxytocin bolus. The nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes during the first stage of labor and every 5 minutes during the second stage (Option B). Continuous electronic fetal heart rate monitoring, not intermittent auscultation, is necessary (Option C). The nurse should also monitor maternal intake and output to identify fluid retention, which precedes water intoxication, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions, and death. (Option A) Oxytocin is administered through a secondary IV line connected to a main IV line (ie, isotonic fluid) via the port closest to the client (ie, proximal port). This helps prevent an inadvertent oxytocin bolus and allows for rapid discontinuation of infusion. (Option E) Oxytocin is not titrated according to cervical dilation, which cannot be assessed continuously and varies among clients. Instead, oxytocin is initiated at the lowest possible dose and titrated until contractions are 2-3 minutes apart and last for 80-90 seconds. The infusion is decreased/discontinued if uterine tachysystole (ie, >5 contractions in 10 minutes) or fetal distress occurs. Educational objective: Oxytocin is a high-alert medication requiring precise administration via a secondary IV line on an electronic infusion pump and frequent maternal/fetal assessment. The medication is titrated to achieve an adequate contraction pattern without causing uterine tachysystole or fetal distress.

A Nurse Is Preparing to Administer Oxytocin to Induce Labor