A nurse is caring for a client who is receiving 1 milliunit/min of oxytocin for the induction of labor.
The provider prescription reads to increase the rate by 1 milliunit per/min every 30 min until the client demonstrates an expected labor pattern.
The cervical Bishop score is 2. The monitor indicates contractions every 1 min.
Which of the following findings indicates the nurse should titrate the infusion rate to 2 milliunits/min after the first 30 min?
The client's contractions palpate as mild.
The client experiences spontaneous rupture of membranes.
The client's pain level decreases.
The client's blood pressure stabilizes.
The Correct Answer is A
Choice A rationale
Palpating contractions as mild indicates that the current oxytocin dose is likely insufficient to achieve an expected labor pattern. Oxytocin aims to induce moderate-to-strong uterine contractions, typically occurring every 2-3 minutes, lasting 40-90 seconds. Mild contractions suggest suboptimal uterine activity, justifying an increase in the infusion rate to stimulate more effective contractions.
Choice B rationale
Spontaneous rupture of membranes is a natural progression of labor and does not directly indicate the need to titrate oxytocin based on uterine contraction effectiveness. While rupture of membranes can accelerate labor, the oxytocin titration decisions are primarily based on the intensity and frequency of uterine contractions, not the status of the amniotic sac.
Choice C rationale
A decrease in the client's pain level is not an indicator for titrating oxytocin for labor induction. Pain is subjective and influenced by various factors, including analgesia. Oxytocin titration is guided by objective measures of uterine activity and cervical change, aiming for an adequate labor pattern rather than pain management.
Choice D rationale
Stabilization of the client's blood pressure, while desirable, is not a direct parameter for titrating oxytocin to achieve an expected labor pattern. Oxytocin's primary effect is on uterine contractility, and titration decisions are based on the frequency, duration, and intensity of contractions, and cervical dilation, not systemic blood pressure changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying ice packs aligns with Western medical practices for reducing swelling and pain. However, traditional yin and yang beliefs often emphasize warmth during the postpartum period to restore a perceived loss of "hot" energy after childbirth. Cold applications could be seen as counterproductive to this balance.
Choice B rationale
Maintaining a cool environment would contradict the traditional belief in maintaining warmth for the postpartum client. In many cultures, a "hot-cold" theory dictates that the postpartum period is a "cold" state, requiring warmth to restore balance and prevent illness. A cool room would be perceived as harmful.
Choice C rationale
Providing a warm beverage aligns with traditional yin and yang postpartum care. Childbirth is often seen as a significant loss of "yang" energy (warmth, activity). Consuming warm foods and beverages helps to replenish this energy, promoting restoration of balance and preventing "cold" illnesses according to this belief system.
Choice D rationale
Showering twice daily, especially with cool water, might conflict with traditional postpartum practices that often restrict bathing or emphasize warm baths. The concern is often about preventing "cold" from entering the body and disrupting the balance, as well as conserving energy during a vulnerable period.
Correct Answer is A
Explanation
Choice A rationale
The lecithin/sphingomyelin (L/S) ratio test is a crucial assessment of fetal lung maturity. Lecithin and sphingomyelin are phospholipids that are components of surfactant, a substance vital for reducing surface tension in the alveoli and preventing lung collapse at birth. A ratio of 2: or greater generally indicates adequate lung maturity.
Choice B rationale
The L/S ratio test does not assess the baby's blood type. Fetal blood typing is determined through other methods, such as cordocentesis or maternal blood tests for fetal DNA, if clinically indicated. The L/S ratio specifically evaluates the quantity and ratio of pulmonary surfactants.
Choice C rationale
This test does not check the baby's liver development. Fetal liver development is assessed through different parameters, such as ultrasound visualization of liver size, blood flow characteristics, and specific liver enzyme levels if a concern exists. The L/S ratio is solely focused on pulmonary maturity.
Choice D rationale
The L/S ratio test is not used to check for genetic disorders. Genetic disorders are identified through chromosomal analysis, DNA sequencing, or biochemical tests performed on amniotic fluid cells obtained during amniocentesis, or through chorionic villus sampling. The L/S ratio is a physiological marker of lung readiness.
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