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.

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Correct Answer is B

Explanation

To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP.

Given the LMP of July 27 (0727):

Add 1 year: July 27, 2023 becomes July 27, 2024.
Add 7 days: July 27, 2024 becomes August 3, 2024.
Subtract 3 months: August 3, 2024 becomes May 3, 2024.

So, the estimated date of birth (EDB) is May 3, 2024 (0503).

A. Expulsion of a blood-tinged mucous plug B. Pressure on the perineum causing the client to bear down C. Continuous contraction lasting 2 min D. Expulsion of clear fluid from the vagina

Correct Answer is C

Explanation

Continuous contractions lasting 2 minutes could indicate uterine tetany, which could lead to uterine rupture, a life-threatening situation that requires immediate medical attention.

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Naxlex Comprehensive Predictor Exams

What is the estimated date of birth (EDB) for a client who is pregnant and whose last menstrual period began on July 27? (State the date in MMDD. For example, July 27 is 0727)

Correct Answer is B

Explanation

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor, which of the following assessment findings should the nurse report to the provider first?

Correct Answer is C

Explanation

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 patient who is 7 days postpartum and calls the clinic to report pain and redness in her left calf. Besides seeing her provider, which interventions should the nurse suggest?

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

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

Select the 4 assessment findings the nurse should report to the provider. Exhibits A nurse in an antepartum clinic is caring for a client who is pregnant. Exhibits:

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following complications as the priority focus of care?