A nurse is assessing a client who is receiving oxytocin infusion to augment labor. Which of the following findings should the nurse identify as an adverse effect of the medication?
Uterine contractions lasting 90 seconds
Moderate variability of the FHR
Uterine contractions every 2 min
FHR 150/min
The Correct Answer is A
Choice A reason: Prolonged uterine contractions lasting 90 seconds indicate uterine tachysystole, a dangerous adverse effect of oxytocin. This can reduce placental perfusion, compromise fetal oxygenation, and increase risk of uterine rupture. Immediate intervention is required.
Choice B reason: Moderate variability of the fetal heart rate is a reassuring sign of adequate oxygenation and intact neurological function. It is not an adverse effect.
Choice C reason: Contractions every 2 minutes are within the normal therapeutic range for oxytocin augmentation. This frequency supports labor progression without compromising fetal well-being.
Choice D reason: A fetal heart rate of 150/min is within the normal baseline range (110–160/min). This is not an adverse effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering an IV diuretic is important to reduce fluid overload, but it is not the immediate priority. Diuretics take time to act, and the client’s oxygenation must be stabilized first.
Choice B reason: Requesting an analysis of ABGs provides valuable diagnostic information, but it is not the priority intervention. ABG analysis does not directly improve oxygenation or relieve symptoms in the acute phase.
Choice C reason: Initiating oxygen via face mask is the priority because pulmonary edema impairs gas exchange, leading to hypoxemia. Immediate oxygen administration improves oxygen saturation and prevents tissue hypoxia while other interventions are prepared.
Choice D reason: Inserting an indwelling urinary catheter may be necessary for monitoring urine output when diuretics are administered, but it is not urgent compared to restoring oxygenation.
Correct Answer is A
Explanation
Choice A reason: Glucosamine supplements are often derived from shellfish. Clients with shellfish allergies may experience allergic reactions when taking glucosamine. Therefore, assessing for shellfish allergy is essential before recommending or approving glucosamine use.
Choice B reason: A history of smoking is not a contraindication for glucosamine. While smoking has negative health effects, it does not interact with glucosamine supplementation.
Choice C reason: Cardiac dysrhythmias are not directly affected by glucosamine. There is no evidence that glucosamine worsens or triggers arrhythmias.
Choice D reason: Malignant hyperthermia is a genetic condition triggered by certain anesthetics, not by glucosamine supplementation. This is not a contraindication.
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