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 ["A","D"]
Explanation
Choice A rationale
Providing an opportunity to connect with others who have experienced similar losses offers significant psychosocial support. Sharing experiences can normalize grief, reduce feelings of isolation, and validate emotions. This peer support can facilitate the grieving process by fostering a sense of community and understanding during a challenging time.
Choice B rationale
While some causes of spontaneous abortion can be identified, many remain unknown even after the expulsion of fetal tissue. Genetic anomalies, chromosomal abnormalities, or uterine factors are often implicated, but a definitive cause is not always determined. Providing this information can create unrealistic expectations and potential disappointment for the client.
Choice C rationale
The decision to view fetal remains is highly personal and depends on individual coping mechanisms and cultural beliefs. For some, it can be a crucial part of acknowledging the loss and beginning the grieving process. Advising against it prematurely removes a potential avenue for closure and validation for the client.
Choice D rationale
Validating the client's grief, regardless of the gestational age, is crucial for emotional well-being. Acknowledging that it is "okay to feel some grief now" provides permission for the client to experience their emotions. Grief is a subjective process, and the intensity and duration are not dictated by the length of the pregnancy.
Correct Answer is B
Explanation
Choice A rationale
Group B Streptococcus (GBS) screening is typically performed much later in pregnancy, usually between 35 and 37 weeks of gestation. This screening is crucial for identifying carriers and administering prophylactic antibiotics during labor to prevent vertical transmission to the newborn, which can cause severe infections like sepsis or meningitis.
Choice B rationale
Human immunodeficiency virus (HIV) screening is a standard diagnostic test offered to all pregnant clients during their first prenatal visit, typically around 12 weeks of gestation. Early detection allows for timely interventions, such as antiretroviral therapy, to reduce the risk of mother-to-child transmission and improve maternal health outcomes.
Choice C rationale
Chorionic villus sampling (CVS) is an invasive diagnostic procedure performed earlier in pregnancy, usually between 10 and 13 weeks of gestation, but it is not a routine screening test. It is typically offered to clients at high risk for genetic disorders due to family history, advanced maternal age, or abnormal prenatal screening results.
Choice D rationale
Cervical cone biopsy is a diagnostic and therapeutic procedure used to remove a cone-shaped piece of tissue from the cervix, typically to evaluate or treat abnormal cervical cells. It is not a routine diagnostic test during a normal prenatal visit and is usually performed prior to pregnancy or if there are specific gynecological concerns.
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