A nurse on the labor and delivery unit is caring for a patient who is having induction of labor 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/minute, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over.

Which of the following actions should the nurse take?

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 selution.

Slow the client's rate of breathing.

Answer and Explanation

The Correct Answer is B

A.   Incorrect. Increasing the rate of infusion of the IV oxytocin would worsen the uterine hyperstimulation and fetal distress that are indicated by the frequent, long, and strong contractions and uniform decelerations.
B.   Correct. Discontinuing the infusion of the IV oxytocin would stop the uterine hyperstimulation and allow the fetus to recover from hypoxia.
C.   Incorrect. Decreasing the rate of infusion of the maintenance IV solution would not affect the uterine hyperstimulation or fetal distress, as they are caused by the oxytocin, not by the fluid volume.
D.   Incorrect. Slowing the client's rate of breathing would not help with the uterine hyperstimulation or fetal distress, as they are not related to maternal hyperventilation or respiratory alkalosis.

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Correct Answer is B

Explanation

Choice A reason:

Monitoring weight gain is correct because appropriate weight gain helps support fetal growth and reduces risks of complications such as gestational diabetes and preeclampsia.

Choice B reason:

Using nonprescription medications without provider approval is unsafe since many over-the-counter drugs (like NSAIDs or decongestants) can harm the fetus. This shows a need for further teaching.

Choice C reason:

Telling the provider before using home remedies is appropriate, as some herbs or supplements may be unsafe in pregnancy.

Choice D reason:

Reducing stress is correct because high maternal stress can negatively affect pregnancy outcomes and fetal development.

A. "Assist the client in slowing her hyperventilation and breathe into a paper bag." B. "Administer oxygen via nasal cannula while encouraging her to pant." C. "Have the client tuck her chin to her chest." D. "Instruct the client to increase her respiratory rate to more than 42 breaths per minute."

Correct Answer is A

Explanation

Choice A: The client's symptoms of lightheadedness and tingling fingers indicate that she may be hyperventilating, which can occur when patternpaced breathing is too rapid. Breathing into a paper bag can help the client rebreathe some of the exhaled carbon dioxide, which can help correct the respiratory alkalosis caused by hyperventilation.

Choice B: Administering oxygen via nasal cannula may not address the underlying issue of hyperventilation. It is more appropriate to assist the client in slowing down her breathing pattern.

Choice C: Tucking the chin to the chest is not relevant to the client's symptoms of hyperventilation.

Choice D: Instructing the client to increase her respiratory rate would exacerbate the hyperventilation, leading to more symptoms of respiratory alkalosis.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

A nurse is providing dietary education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone (Cervidil) gel. Which of the following statements should the nurse include in the teaching?

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?