A nurse is caring for a patient in labor who is receiving oxytocin (Pitocin) by IV infusion to stimulate uterine contractions.
Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?
Fetal heart rate of 90 beats per minute
Increased urinary output
Three contractions occurring within a 10-minute period
Adequate resting tone of the uterus palpated between contractions
Adequate resting tone of the uterus palpated between contractions
The Correct Answer is A
Choice A rationale:
Fetal heart rate of 90 beats per minute is a sign of fetal bradycardia, which is a serious and potentially life-threatening condition. It indicates that the fetus is not getting enough oxygen, and it can lead to fetal distress, brain damage, or even death.
Oxytocin can cause uterine hyperstimulation, which can reduce blood flow to the placenta and cause fetal bradycardia. Therefore, if the nurse observes a fetal heart rate of 90 beats per minute, it is essential to discontinue the oxytocin infusion immediately and notify the healthcare provider.
Choice B rationale:
Increased urinary output is not a direct contraindication to oxytocin administration. In fact, oxytocin can sometimes cause a decrease in urinary output due to its antidiuretic effects.
While a significant increase in urinary output could be a sign of fluid overload, it would not necessarily indicate that the oxytocin infusion needs to be discontinued. The nurse would need to assess the patient's overall fluid status and other clinical indicators to make this determination.
Choice C rationale:
Three contractions occurring within a 10-minute period is considered a normal contraction pattern during labor. It is not a sign of uterine hyperstimulation or fetal distress.
In fact, the goal of oxytocin administration is to achieve regular contractions that are occurring every 2-3 minutes and lasting 40-60 seconds. Therefore, this finding would not indicate that the oxytocin infusion needs to be discontinued.
Choice D rationale:
Adequate resting tone of the uterus palpated between contractions is a normal finding during labor. It indicates that the uterus is contracting effectively and is not at risk for uterine atony (lack of muscle tone).
This finding would not be a reason to discontinue the oxytocin infusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Visceral pain arises from the internal organs and is often described as dull, aching, cramping, or squeezing. During the first stage of labor, the uterus contracts forcefully to dilate the cervix and move the baby down the birth canal. This stretching and pressure on the uterus, cervix, and other pelvic organs stimulate pain receptors, resulting in visceral pain. This pain is typically located in the lower abdomen, back, and groin.
Key points about visceral pain in the first stage of labor:
It's often described as dull, aching, cramping, or squeezing.
It's caused by the stretching and pressure on the uterus, cervix, and other pelvic organs.
It's typically located in the lower abdomen, back, and groin.
It can be intermittent or continuous.
It can vary in intensity from mild to severe.
It's often accompanied by other symptoms such as nausea, vomiting, sweating, and anxiety.
Choice B rationale:
Referred pain is pain that is felt in a different location from the source of the pain. It's not typically associated with the first stage of labor.
Choice C rationale:
Somatic pain arises from the skin, muscles, bones, and joints. It's often described as sharp, stabbing, burning, or throbbing. The somatic pain of the second stage of labor is caused by the stretching and distension of the perineum and vagina as the baby descends. It's typically located in the lower back, buttocks, and thighs.
Choice D rationale:
Pain during the third stage of labor is typically mild compared to the first and second stages. It's caused by the contractions of the uterus as it expels the placenta. It's usually located in the lower abdomen and may be accompanied by a feeling of pressure or fullness.
Correct Answer is C
Explanation
Choice A rationale:
Drug/alcohol use: While substance abuse during pregnancy can lead to adverse outcomes such as preterm labor, fetal growth restriction, and birth defects, it is not considered a primary factor in determining high-risk status for this patient. The specific substances involved (cocaine and alcohol) are indeed associated with risks, but they are not as significant as other factors in this case.
Age: The patient's age of 24 is not considered a high-risk factor for pregnancy. Advanced maternal age (typically defined as 35 years or older) is associated with increased risks for chromosomal abnormalities and other complications, but this patient falls below that age threshold.
Family history: Family history of diabetes mellitus, cancer, and neural tube defects can be relevant to pregnancy risk, but in this case, other factors outweigh their significance.
Choice B rationale:
Blood pressure: The patient's blood pressure of 108/70 mm Hg is within the normal range and does not contribute to highrisk categorization. High blood pressure (hypertension) during pregnancy can lead to preeclampsia and other complications, but this patient does not present with hypertension.
Age: As explained in Choice A, the patient's age is not a high-risk factor.
BMI: A BMI of 17 is considered underweight, which can increase the risk of certain pregnancy complications such as preterm birth and low birth weight. However, in this case, other factors are more significant in determining high-risk status.
Choice C rationale:
Family history: The patient's family history of a neural tube defect (NTD) in a close relative is a significant risk factor for NTDs in her own pregnancy. NTDs are serious birth defects that affect the brain and spinal cord, and they can have lifelong implications for the child. This factor alone warrants a high-risk categorization.
BMI: The patient's underweight BMI of 17 further contributes to her high-risk status, as it can increase the likelihood of certain complications as mentioned earlier.
Drug/alcohol abuse: The patient's admission of cocaine and alcohol use, even if occasional, is a concerning factor for pregnancy. Cocaine, in particular, is a potent vasoconstrictor that can negatively impact fetal growth and development. Alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders (FASDs), which can cause a range of physical, cognitive, and behavioral problems.
Choice D rationale:
Age: As explained previously, the patient's age is not a high-risk factor.
BMI: The patient's BMI is a contributing factor, but not the most significant one in this case.
Family history: The patient's family history is relevant, but the presence of a neural tube defect in a close relative is the most significant aspect of her family history in terms of pregnancy risk.
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