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 A
Explanation
Choice A rationale
The nurse should close the newborn’s eyes before applying eyepatches. This is because the intense light used in phototherapy can harm the newborn’s eyes. Therefore, protective eye patches are used to shield the newborn’s eyes from the light while allowing the rest of the body to be exposed to the light. This helps to convert the bilirubin in the skin into a form that can be easily eliminated from the body.
Choice B rationale
Turning the newborn every 4 hours is not specifically related to phototherapy. While turning is important for preventing pressure ulcers, it does not directly impact the effectiveness of phototherapy. The primary goal of phototherapy is to expose as much of the newborn’s skin as possible to the light, which helps to reduce the level of bilirubin.
Choice C rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The use of lotions or creams can block the light and reduce the effectiveness of phototherapy. The skin should be clean and free of any barriers to light penetration.
Choice D rationale
Providing the newborn with 15 mL glucose water after each feeding is not directly related to phototherapy. While maintaining hydration is important for all newborns, it does not specifically enhance the effectiveness of phototherapy for jaundice.
Correct Answer is B
Explanation
Choice A rationale
Applying firm pressure on the client’s suprapubic area is not part of the McRoberts maneuver. This action is more associated with the suprapubic pressure technique, which is another method used to manage shoulder dystocia.
Choice B rationale
The McRoberts maneuver involves having the client flex her hips against her abdomen. This is achieved by assisting the client in pulling her knees toward her abdomen.
Choice C rationale
Applying pressure to the client’s fundus is not part of the McRoberts maneuver and can be contraindicated as it may cause additional complications.
Choice D rationale
Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position is more associated with the all-fours maneuver, also known as the Gaskin maneuver.
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