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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Ceftriaxone (Rocephin) is an antibiotic that is often used to treat bacterial infections, but it is not typically the first line of treatment for herpes.
Choice B rationale

Penicillin G intravenously is a type of antibiotic that is often used to treat bacterial infections. However, herpes is a viral infection, and antibiotics are not effective against viruses.
Choice C rationale
Acyclovir is an antiviral medication that is commonly used to treat herpes infections. It works by slowing the growth and spread of the herpes virus in the body. This would be the most appropriate treatment for a patient presenting with symptoms of a herpes outbreak.
Choice D rationale
Betamethasone is a type of corticosteroid that is often used to reduce inflammation. While it might help to reduce some of the inflammation and discomfort associated with herpes lesions, it would not address the underlying viral infection.

A. At the level of the umbilicus B. To the right of the umbilicus C. One fingerbreadth above the symphysis pubis D. 2 cm above the umbilicus E. 2 cm above the umbilicus

Correct Answer is A

Explanation

At the level of the umbilicus. After a vaginal delivery, the nurse should expect to find the uterine fundus at the level of the umbilicus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

Correct Answer is A

Explanation

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and believes she is in labor. Which finding confirms to the nurse that the client is in labor?

What could be the result of fetal head compression?

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply)

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client’s bladder is distended?

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply)

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. What information should the nurse give to the client?

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?