A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
Prepare the equipment necessary to initiate an amnioinfusion.
Administer oxygen at 10 L/min via a nonrebreather face mask.
Discontinue the infusion of oxytocin.
Place the client in a left lateral position.
The Correct Answer is D
Choice A reason:
Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Choice B reason:
Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.
Choice C reason:
Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.
Choice D reason:
This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.
Choice B rationale:
An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.
Choice C rationale:
Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.
Choice D rationale:
A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.
Correct Answer is C
Explanation
Choice A rationale:
Polyuria is not an adverse effect of epidural anesthesia. It is unrelated to this type of pain control.
Choice B rationale:
Hypertension is not an adverse effect of epidural anesthesia. Epidurals can actually cause a decrease in blood pressure due to vasodilation.
Choice C rationale:
This is the correct choice. Pruritus, or itching, is a common adverse effect of epidural anesthesia caused by the release of histamines from local anesthetics.
Choice D rationale:
Dry mouth is not an adverse effect of epidural anesthesia. Dry mouth is more commonly associated with general anesthesia or medications with anticholinergic effects.
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