A nurse is caring for a patient who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR.
After discontinuing the infusion, what action should the nurse take?
Initiate an amnioinfusion.
Place the patient in a supine position.
Instruct the patient to bear down and push with contractions.
Administer oxygen at 10 L/min via non-rebreather face mask.
The Correct Answer is D
Choice A rationale
Initiating an amnioinfusion is not the first action to take after discontinuing oxytocin infusion due to persistent late decelerations in the FHR. Amnioinfusion is a procedure where a saline solution is infused into the uterus to increase the volume of amniotic fluid. It is typically used to treat variable decelerations in the FHR, not late decelerations.
Choice B rationale
Placing the patient in a supine position is not recommended as it can decrease blood flow to the uterus and fetus, potentially worsening the late decelerations.
Choice C rationale
Instructing the patient to bear down and push with contractions is not appropriate in this situation. Persistent late decelerations in the FHR are a sign of fetal distress, and further contractions could exacerbate this.
Choice D rationale
Administering oxygen at 10 L/min via a non-rebreather face mask is the correct action. This increases the amount of oxygen available to the mother and fetus, potentially improving the FHR pattern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A hematocrit level of 37% is within the normal range for a pregnant woman, which is 33% to 46%. Therefore, this result does not need to be reported to the provider.
Choice B rationale
A fasting blood glucose level of 180 mg/dL is significantly higher than the normal range of 74 to 106 mg/dL. This could indicate gestational diabetes, which can lead to various complications for both the mother and the baby. Therefore, this finding should be reported to the provider.
Choice C rationale
A creatinine level of 0.9 mg/dL is within the normal range of 0.5 to 1 mg/dL for a female client aged 18 to 40 years.
Choice D rationale
A WBC count of 11,000/mm is slightly above the normal range of 5,000 to 10,000/mm. However, it’s common for the WBC count to increase during pregnancy due to physiological changes. Therefore, this result does not need to be reported to the provider.
Correct Answer is C
Explanation
Choice A rationale
Bronchopulmonary dysplasia is a chronic lung disease that affects newborns and infants, but it is not a complication of forceps-assisted birth. It’s more common in premature babies who have been treated with oxygen and positive-pressure ventilation.
Choice B rationale
Polycythemia, a condition characterized by an increased number of red blood cells, is not a complication of forceps-assisted birth. It can occur due to various reasons, including high altitude and certain genetic disorders.
Choice C rationale
Facial palsy can occur as a complication of forceps-assisted birth. The pressure exerted by the forceps can cause damage to the facial nerve, leading to temporary or permanent facial weakness or paralysis.
Choice D rationale
Hypoglycemia, or low blood sugar, is not a complication of forceps-assisted birth. It’s more commonly seen in babies of mothers with diabetes, premature babies, and babies who are small for their gestational age.
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