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
Choice A rationale
A temperature of 37.4°C (99.3°F) is within the normal range and does not indicate endometritis.
Choice B rationale
Scant lochia is not typically associated with endometritis. In fact, women with endometritis may experience heavy lochia or foul-smelling lochia.
Choice C rationale
A WBC count of 9,000/mm is within the normal range and does not indicate endometritis.
Choice D rationale
Uterine tenderness is a common symptom of endometritis. Other symptoms can include fever, malaise, and foul-smelling lochia.
Correct Answer is D
Explanation
The correct answer is choice d. The procedure is not necessary to determine the sex of the fetus.
Choice A rationale:
Chorionic villus sampling (CVS) is another prenatal test that can determine the sex of the fetus, but it is typically performed between 10-13 weeks of gestation. However, it is not the standard response to a request for amniocentesis.
Choice B rationale:
Age is not a criterion for performing an amniocentesis. This procedure can be done for various medical reasons regardless of the mother’s age.
Choice C rationale:
Scheduling an amniocentesis for the same day is not appropriate, especially since the primary purpose of amniocentesis is to diagnose genetic disorders, not to determine the sex of the fetus.
Choice D rationale:
This is the correct response because non-invasive methods like ultrasound can determine the sex of the fetus without the need for an invasive procedure like amniocentesis, which carries risks.
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