A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of labor.
The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction.
What action should the nurse implement at this time?
Administer 10 L of oxygen via face mask.
Place the client on her left side.
Discontinue the oxytocin (Pitocin) infusion.
Notify the healthcare provider.
The Correct Answer is C
Discontinue the oxytocin (Pitocin) infusion. This is because the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction indicate a late deceleration, which is a sign of fetal hypoxia. Oxytocin is a drug that stimulates uterine contractions and can cause uterine hyperstimulation, which reduces blood flow to the placenta and the fetus. By stopping the oxytocin infusion, the nurse can reduce the frequency and intensity of contractions and improve fetal oxygenation.
Choice A is wrong because administering oxygen via facemask may not be enough to reverse fetal hypoxia if oxytocin is still being infused. Choice B is wrong because placing the client on her left side may improve maternal blood flow to the placenta, but it will not reduce the effects of oxytocin on uterine activity.
Choice D is wrong because notifying the healthcare provider is not the most urgent action at this time. The nurse should first discontinue the oxytocin infusion and then notify the healthcare provider.
Normal ranges for FHR are 110 to 160 beats per minute, with a baseline variability of 6 to 25 beats per minute.
Normal ranges for uterine contractions are 2 to 5 contractions in 10 minutes, lasting
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Absent Moro reflex on the affected side indicates a possible injury to the brachial plexus, which is the nerve network that controls the movements and sensations of the shoulder, arm, hand and fingers.Shoulder dystocia can cause brachial plexus injuries when the baby’s shoulder gets stuck behind the mother’s pubic bone during delivery.
Choice B is wrong because flaccid paralysis of both lower extremities is not a common complication of shoulder dystocia.
It could be a sign of spinal cord injury or other neurological disorders.
Choice C is wrong because facial asymmetry when crying or smiling is a sign of facial nerve palsy, which can occur due to compression of the facial nerve during delivery.
It is not specific to shoulder dystocia.
Choice D is wrong because inability to suck or swallow is not a typical sign of shoulder dystocia.
It could be caused by other factors such as prematurity, neurological problems, or congenital anomalies.
Normal ranges for Moro reflex are present at birth and disappear by 4 to 6 months of age.
Normal ranges for facial nerve function are symmetrical movements of both sides of the face.
Normal ranges for sucking and swallowing are coordinated and effective feeding within the first hour after birth.
Correct Answer is D
Explanation
Phototherapy is a treatment that uses light to break down bilirubin in the blood and make it easier for the liver to eliminate it.
Phototherapy is effective when:
• The bilirubin levels decrease within 24 hours of treatment.
This means that the bilirubin is being cleared faster than it is being produced.
• The urine output and stool frequency increase during treatment.
This means that the bilirubin is being excreted through the kidneys and intestines.
• The skin color and muscle tone improve after treatment.
This means that the bilirubin is no longer causing jaundice or affecting the nervous system.
Statement A is wrong because it only describes one aspect of phototherapy effectiveness.
Statement B is wrong because it only describes another aspect of phototherapy effectiveness.
Statement C is wrong because it only describes the outcome of phototherapy effectiveness.
Statement D is correct because it includes all three aspects of phototherapy effectiveness.
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