A nurse is monitoring the labor of a patient who is receiving IV oxytocin (Pitocin) at 6 ml/hr. Which of the following clinical signs would lead the nurse to stop the infusion?

Maternal temperature of 101.4 F

Maternal blood pressure of 138/89

Change in fetal baseline heart rate from 125 to 90

Change in the maternal pulse from 80 to 93

Answer and Explanation

The Correct Answer is C

A. Maternal temperature of 101.4°F. A fever may indicate infection (chorioamnionitis), but it is not an immediate reason to stop oxytocin. The nurse should monitor for additional signs of infection and notify the provider, but the priority is fetal well-being.

B. Maternal blood pressure of 138/89. This blood pressure is not critically high and does not indicate a hypertensive crisis. Oxytocin can cause fluid retention and slight blood pressure changes, but this reading alone does not require stopping the infusion.

C. Change in fetal baseline heart rate from 125 to 90. A decrease in fetal heart rate (bradycardia) is a sign of fetal distress and requires immediate intervention. Oxytocin can cause uterine hyperstimulation, leading to decreased placental perfusion and fetal hypoxia. The priority is to stop oxytocin, reposition the mother, provide oxygen, and notify the provider.

D. Change in the maternal pulse from 80 to 93. A mild increase in heart rate is not uncommon during labor and may be due to pain, anxiety, or IV fluids. It does not indicate an emergency or the need to stop oxytocin.

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Correct Answer is D

Explanation

A. No action is necessary since a decrease in the woman's blood pressure is expected. While a drop in blood pressure is a common side effect of a spinal block, a 20% decrease is significant and can compromise placental perfusion, leading to fetal distress. Intervention is necessary to restore circulation.

B. Decrease her intravenous (IV) rate to a keep vein-open rate. This is incorrect because IV fluids help counteract hypotension. Instead of decreasing the IV rate, the nurse may need to increase fluid administration to improve blood pressure and maintain perfusion.

C. Encourage her to empty her bladder. A full bladder can affect labor progression but does not directly cause or correct hypotension. The priority in this scenario is restoring blood pressure to ensure adequate fetal oxygenation.

D. Turn the woman to the left lateral position or place a pillow under her hip. This is the most appropriate intervention. A left lateral position or elevating her right hip helps relieve aortocaval compression, improving blood flow to the uterus and stabilizing blood pressure. Additional interventions, such as IV fluid boluses or vasopressors (e.g., ephedrine), may be needed if hypotension persists.

A. True B. False

Correct Answer is A

Explanation

Professor Proctor emphasizes safety as the highest priority while traveling, including when coming to class. Ensuring that students arrive safely is considered more important than strict punctuality.

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A nurse is monitoring the labor of a patient who is receiving IV oxytocin (Pitocin) at 6 ml/hr. Which of the following clinical signs would lead the nurse to stop the infusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?

Correct Answer is D

Explanation

Professor Proctor: Always wants us to be safe while traveling anywhere- especially when coming to class. This is prioritized even over being on time.

Correct Answer is A

Explanation

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