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 D

Explanation

Choice A: Pain above the umbilicus may be associated with various conditions during pregnancy, but it is not a definitive sign of labor.

Choice B: The presence of amniotic fluid in the vaginal vault (rupture of membranes or "water breaking") can be a sign of labor, but it is not the most specific indicator.

Choice C: Brownish vaginal discharge may indicate the passage of old blood or "bloody show," which can be a sign of impending labor. However, it is not as reliable as cervical dilation.

Choice D: Cervical dilation is one of the most definitive signs of labor. As the cervix opens and thins (effaces), it allows for the baby's passage through the birth canal. Cervical dilation is an essential indicator of active labor.

A. Quickening B. Ballottement C. Chloasma D. Lightening

Correct Answer is A

Explanation

A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. The nurse uses Naegele's Rule to calculate the correct EDD:

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action immediately following this procedure?

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?