A nurse is caring for a client who is in labor and receiving oxytocin. The electronic fetal monitor indicates contractions every 50 seconds, lasting 2 min and late decelerations. Which of the following actions should the nurse take?
Slow down the oxytocin infusion
Administer oxygen at 2 L/min per nasal cannula
Place the client in a lithotomy position for delivery.
increase the rate of IV fluid infusion of lactated Ringers
The Correct Answer is A
Rationale:
A. Slow down the oxytocin infusion: Contractions occurring every 50 seconds and lasting 2 minutes indicate severe uterine hyperstimulation, which reduces placental blood flow and contributes to late decelerations. Slowing or stopping the oxytocin helps decrease contraction intensity and frequency, improving fetal oxygenation.
B. Administer oxygen at 2 L/min per nasal cannula: Oxygen administration can support fetal oxygenation, but 2 L/min via nasal cannula delivers minimal benefit in an acute distress situation. Oxygen would be used as a supportive measure after correcting the cause of the late decelerations. The first action is reducing uterine activity by adjusting the oxytocin infusion.
C. Place the client in a lithotomy position for delivery: Lithotomy positioning is used during the second stage of labor but is inappropriate when the fetus shows signs of distress. It does not relieve uterine hyperstimulation or improve placental blood flow. Positioning that enhances perfusion, such as side-lying, would be more beneficial after reducing the oxytocin.
D. Increase the rate of IV fluid infusion of lactated Ringers: Increasing IV fluids may help improve maternal circulation, but it does not directly resolve contractions that are too frequent or prolonged. Fluids can be an adjunct intervention but should not occur before decreasing oxytocin in the presence of late decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.
B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.
C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.
D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.
Correct Answer is B
Explanation
Rationale:
A. Disulfiram: Disulfiram is used to support alcohol abstinence by causing unpleasant reactions when alcohol is consumed. It does not reverse opioid overdose and is not indicated for morphine toxicity.
B. Naloxone: Naloxone is an opioid antagonist that binds to opioid receptors and rapidly reverses the effects of morphine and other opioids. It is the first-line treatment for opioid overdose, effectively restoring respiratory function and alertness.
C. Activated charcoal: Activated charcoal can adsorb certain ingested toxins in the gastrointestinal tract, but it is not effective for opioids already absorbed systemically, such as in a morphine overdose.
D. Flumaren: Flumazenil (Flumaren) is a benzodiazepine antagonist used to reverse benzodiazepine overdose, not opioid toxicity. It has no effect on morphine or other opioids.
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