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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale
Thrombophlebitis is a condition where a blood clot in a vein causes inflammation and pain. While it can occur postpartum, it is not directly related to the weight of the newborn.
Choice B rationale
Retained placental fragments can occur after childbirth and can lead to postpartum hemorrhage or infection. However, this complication is not directly related to the weight of the newborn.
Choice C rationale
Puerperal infection, also known as postpartum infection, can occur after childbirth. However, it is not directly related to the weight of the newborn.
Choice D rationale
Uterine atony, a condition where the uterus fails to contract after the delivery of the baby, is a common cause of postpartum hemorrhage. A larger newborn, such as one weighing 9 lb 6 oz, can overstretch the uterus, increasing the risk of uterine atony.

A. Prepare to administer oxytocic medication. B. Assist the client on a bedpan to urinate. C. Palpate the client’s uterine fundus. D. Increase the client’s fluid intake.

Correct Answer is C

Explanation

Choice A rationale
Administering oxytocic medication is an intervention that may be necessary if the client’s bleeding does not stop or if the uterus does not contract adequately. However, the priority is to assess the situation, which includes palpating the uterine fundus.
Choice B rationale
Assisting the client on a bedpan to urinate can help if the bladder is full and preventing the uterus from contracting properly. However, the priority is to assess the uterus by palpating the uterine fundus.
Choice C rationale
Palpating the client’s uterine fundus is the priority nursing intervention. A boggy uterus (one that does not contract properly) is a common cause of postpartum hemorrhage. If the uterus is not firm upon palpation, massage it until it firms up.
Choice D rationale
Increasing the client’s fluid intake can help replace lost fluids, but it is not the priority intervention. The first step is to assess the cause of the bleeding, which includes palpating the uterine fundus.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which postpartum complications?

Correct Answer is D

Explanation

A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period. What should be the priority nursing intervention at this time?

Correct Answer is C

Explanation

Which of the following observations should be recorded as part of a newborn gestational age assessment?

A nurse is preparing to administer magnesium sulfate IV to a client who is in labor. Which of the following is the primary nursing assessment for this client?

A nurse is performing a physical examination of a client who is 1 day postpartum. Which finding requires immediate attention?

A nurse in the newborn unit is caring for several infants. Which of the following situations requires the nurse's immediate attention and intervention?

A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse’s planned actions are anticipated, nonessential, or contraindicated.

A nurse is educating the mother of a newborn who was born small for gestational age. Which of the following should the nurse mention as a potential cause of this condition?

A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. Which of the following responses by the nurse would be therapeutic?

A nurse in a prenatal clinic is caring for a client whose blood pressure is 80/40 mm Hg. The client’s last menstrual period was on May 4, 2023. What would be the estimated due date for the client?