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 C
Explanation
Labetalol is an antihypertensive drug that can lower blood pressure in pregnant women with preeclampsia.Preeclampsia is a condition that causes high blood pressure and proteinuria after 20 weeks of gestation.
Choice A is wrong because hydralazine is not recommended as a first-line treatment for preeclampsia due to its potential adverse effects on maternal and fetal outcomes.
Choice B is wrong because nifedipine is not licensed for use in pregnancy and may interact with magnesium sulfate, which is an anticonvulsant medication used to prevent or treat seizures in severe preeclampsia.
Choice D is wrong because methyldopa is not effective for acute blood pressure control and may cause adverse effects such as depression, sedation, and hemolytic anemia.
Correct Answer is D
Explanation
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
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