A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?

Administer oxygen at 10 L/min via nonrebreather facemask.

Initiate an amnioinfusion.

Instruct the client to bear down and push with contractions.

Place the client in a supine position.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Administering oxygen helps improve oxygenation to the fetus and is the priority intervention for late decelerations.

B. Amnioinfusion may be considered for variable decelerations caused by oligohydramnios but is not indicated for late decelerations.

C. Instructing the client to bear down and push with contractions is not appropriate for addressing late decelerations and may worsen fetal distress.

D. Placing the client in a supine position can exacerbate late decelerations by reducing blood flow to the uterus and should be avoided.

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Correct Answer is A

Explanation

Rationale:

A. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids, including saliva and urine.

B. Airborne precautions are not necessary for cytomegalovirus, as it is primarily transmitted through contact with infected bodily fluids, not through airborne droplets.

C. There is no prophylactic treatment with acyclovir for cytomegalovirus; treatment options are limited and typically reserved for severe cases.

D. Lesions are not typically visible on the mother's genitalia with cytomegalovirus; the virus is often asymptomatic or causes mild symptoms in healthy adults.

A. To facilitate bonding between the newborn and parent B. To allow manifestations of infection to be identified C. The newborn weighs less than 2.5 kg (5.5 lb) D. The newborn was delivered via cesarean birth

Correct Answer is A

Explanation

A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.

B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.

C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.

D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.

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A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

Correct Answer is A

Explanation

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