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

A) Retained bile in the liver results in delayed digestion: This statement is not related to the cause of heartburn.
B) Increased estrogen production causes increased secretion of hydrochloric acid: While hormonal changes during pregnancy can contribute to heartburn, it is specifically increased progesterone that leads to relaxation of the cardiac sphincter and delayed gastric emptying, which are more directly linked to heartburn.
C) Pressure from the growing uterus displaces the stomach: Uterine pressure on the stomach can lead to a feeling of fullness, but it is not the primary cause of heartburn during pregnancy.
D) Increased progesterone production causes relaxation of the smooth muscle relaxation of the cardiac sphincter and delayed gastric emptying: This is the correct answer. Increased progesterone levels during pregnancy relax the lower esophageal sphincter, leading to gastric acid reflux into the esophagus and causing heartburn.

A. Position the client on her side. B. Elevate the client's legs. C. Increase the infusion rate of the IV fluid. D. Administer oxygen via face mask.

Correct Answer is A

Explanation

A. Position the client on her side: Late decelerations are often associated with uteroplacental insufficiency, which may be improved by changing the maternal position to improve blood flow to the placenta.
B. Elevate the client's legs: Elevating the client's legs would not directly address the cause of late decelerations.
C. Increase the infusion rate of the IV fluid: While ensuring adequate hydration is important, it is not the priority action when late decelerations are noted.
D. Administer oxygen via a face mask: Oxygen administration may be necessary, but it is not the priority action. Positioning the client on her side to improve blood flow is the priority.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Correct Answer is A

Explanation

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

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 delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

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 caring for a client who is a primigravida, at term, and having contractions. The client states that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as the most reliable sign of true labor?