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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which play a crucial role during childbirth. Strengthening these muscles can aid in better control during labor and delivery, facilitating stretching and reducing the risk of injury.
Choice B: Kegel exercises do not have a direct impact on preventing constipation during pregnancy. However, they may help improve bowel control and prevent fecal incontinence.
Choice C: While Kegel exercises can improve posture and core strength, their primary benefit lies in strengthening the pelvic muscles, not directly reducing backaches throughout pregnancy.
Choice D: Kegel exercises are not intended to prevent stretch marks on the abdomen. Stretch marks are caused by the stretching of the skin during pregnancy and are not related to pelvic muscle exercises.
Correct Answer is D
Explanation
Choice A: It is not accurate to say that a repeat cesarean birth will always be safer. The decision for a repeat cesarean or a trial of labor after cesarean (TOLAC) depends on various factors, including the client's medical history and the type of incision used in the previous cesarean.
Choice B: While there are multiple factors to consider, the nurse can still provide general information about the possibility of attempting a vaginal birth after cesarean (VBAC).
Choice C: While focusing on the health of the newborn is important, the client's question about the possibility of a future VBAC can be addressed without dismissing her concerns.
Choice D: The type of incision used in the previous cesarean birth (such as low transverse incision) is a significant factor in determining the eligibility for a VBAC in subsequent pregnancies. Clients with certain types of incisions may have a higher likelihood of success with a VBAC.
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