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 D
Explanation
The correct answer is choice d. Transmission can occur via the saliva and urine of the newborn.
Choice A rationale:
Lesions are not typically visible on the mother’s genitalia with cytomegalovirus (CMV) infection. CMV is often asymptomatic or presents with nonspecific symptoms, and visible lesions are not a characteristic feature.
Choice B rationale:
CMV does not require airborne precautions. It is primarily transmitted through direct contact with bodily fluids such as saliva, urine, blood, and breast milk.
Choice C rationale:
Prophylactic treatment with acyclovir is not standard for CMV. Acyclovir is used for herpes simplex virus infections, not CMV.
Choice D rationale:
CMV can indeed be transmitted via the saliva and urine of the newborn. This is a common mode of transmission, especially in settings like daycare centers where young children are in close contact.
Correct Answer is B
Explanation
Choice A rationale
Frequent urination is a common symptom in early pregnancy due to the increased blood flow to the woman’s kidneys. This is a normal physiological change and does not require immediate attention.
Choice B rationale
Severe vomiting at 8 weeks of gestation could indicate hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy that can lead to dehydration and weight loss. This
condition requires immediate medical attention as it can have serious health implications for both the mother and the baby.
Choice C rationale
Back pain following intercourse at 36 weeks of gestation could be a sign of labor. However, it is not as urgent as severe vomiting in early pregnancy which can lead to dehydration.
Choice D rationale
Periodic tingling of the fingers at 24 weeks of gestation could be due to physiological changes in pregnancy such as fluid retention causing carpal tunnel syndrome. While this can be uncomfortable, it is not a medical emergency.
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