A nurse on the labor and delivery unit is caring for a patient undergoing labor induction with oxytocin administered through a secondary IV line.
Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation.
The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over.
What action should the nurse take?
Slow the client’s rate of breathing.
Increase the rate of infusion of the IV oxytocin.
Discontinue the infusion of the IV oxytocin.
Decrease the rate of infusion of the maintenance IV solution.
The Correct Answer is C
Choice A rationale
Slowing the client’s rate of breathing would not directly address the issue of strong, frequent contractions and uniform decelerations of the fetal heart rate. These symptoms suggest uterine hyperstimulation, which can compromise fetal oxygenation.
Choice B rationale
Increasing the rate of infusion of the IV oxytocin would likely exacerbate the problem, as oxytocin can cause uterine hyperstimulation, leading to reduced fetal oxygen supply.
Choice C rationale
Discontinuing the infusion of the IV oxytocin is the appropriate action. The pattern of contractions and fetal heart rate decelerations suggest uterine hyperstimulation, which can be caused by excessive oxytocin. Stopping the oxytocin infusion can help to normalize the contraction pattern and improve fetal oxygenation.
Choice D rationale
Decreasing the rate of infusion of the maintenance IV solution would not directly address the issue of uterine hyperstimulation and fetal heart rate decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Regular physical activity is an important part of managing gestational diabetes. Most guidelines recommend at least 30 minutes of moderate-intensity exercise on most days of the week. Reducing the exercise schedule to only 3 days a week may not provide enough activity to help regulate blood glucose levels.
Choice B rationale
Limiting carbohydrates to 50% of caloric intake can be a part of a balanced diet for managing gestational diabetes. Carbohydrates have the biggest effect on blood sugar levels, so monitoring and regulating carbohydrate intake is key.
Choice C rationale
Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It helps to lower blood glucose levels by stimulating the pancreas to release more insulin.
Choice D rationale
It is true that women who have had gestational diabetes are at an increased risk of developing type 2 diabetes later in life. Therefore, this statement does not indicate a need for further teaching.
Correct Answer is A
Explanation
Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.
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