A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin.
The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds.
The fetal heart rate is 160 beats/minute with late decelerations.
What is the priority nursing action?
Increase the rate of oxytocin infusion
Administer oxygen via face mask at 10 L/minute
Turn the client to her left side
Notify the health care provider
The Correct Answer is D
The correct answer is d. Notify the health care provider.
Rationale for Choice A:
- Increasing the rate of oxytocin infusion is contraindicated in this situation.
- Oxytocin stimulates uterine contractions, and the client is already experiencing excessively frequent and prolonged contractions.
- Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
- It could also put the client at higher risk for uterine rupture, a serious complication associated with oxytocin use.
Rationale for Choice B:
- While administering oxygen is a common intervention for fetal distress, it's not the priority action in this case.
- Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency, which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
- Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.
Rationale for Choice C:
- Turning the client to her left side is a recommended position to improve placental blood flow.
- However, in this situation, it's not the priority action given the presence of late decelerations and excessive uterine contractions.
- It may be a helpful adjunct measure, but it won't address the primary cause of fetal distress.
Rationale for Choice D:
- Notifying the health care provider is the most crucial action because:
- The client has severe pre-eclampsia, a serious condition that requires close monitoring and management.
- The frequent and prolonged contractions, along with late decelerations in the fetal heart rate, indicate potential fetal distress.
- The health care provider needs to be aware of these changes to make timely decisions regarding interventions, such as:
- Adjusting the oxytocin infusion
- Expediting delivery if necessary
- Implementing other measures to improve fetal well-being
- Closely monitoring the mother's condition to prevent complications of pre-eclampsia
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
The correct answer is choice A and E. The nurse should check the client’s blood pressure and magnesium level before giving hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
• Choice A is correct because hydralazine is an antihypertensive drug that lowers blood pressure by relaxing blood vessels.The nurse should monitor the client’s blood pressure before and after giving hydralazine to ensure that it is within the target range and to avoid hypotension or rebound hypertension.
• Choice B is wrong because pulse oximetry is not directly related to hydralazine administration or pre-eclampsia.Pulse oximetry measures the oxygen saturation of hemoglobin in the blood and can be affected by factors such as anemia, hypothermia, nail polish, or movement.
The nurse should monitor the client’s pulse oximetry as part of routine care, but it is not a priority before giving hydralazine.
• Choice C is wrong because checking the client’s reflexes is not directly related to hydralazine administration or pre-eclampsia.Reflexes are assessed to monitor for signs of magnesium toxicity, which can cause muscle weakness, respiratory depression, and cardiac arrest.
The nurse should check the client’s reflexes as part of routine care, but it is not a priority before giving hydralazine.
• Choice D is wrong because checking the client’s urine specific gravity is not directly related to hydralazine administration or pre-eclampsia.Urine specific gravity measures the concentration of solutes in the urine and can be affected by factors such as hydration status, renal function, or diuretic use.
The nurse should monitor the client’s urine specific gravity as part of routine care, but it is not a priority before giving hydralazine.
• Choice E is correct because magnesium sulfate is a drug that prevents and treats seizures in women with severe pre-eclampsia or eclampsia.The nurse should monitor the client’s magnesium level before and after giving magnesium sulfate to ensure that it is within the therapeutic range and to avoid magnesium toxicity.
Correct Answer is ["A","C"]
Explanation
The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction.Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure.The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.
Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity.Corticosteroids may worsen the liver function and increase the risk of infection.
Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome.Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.
Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome.The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible.Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.
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