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: Variable decelerations on the fetal heart rate monitor tracing are suggestive of umbilical cord compression. These decelerations are often V, U, or Wshaped, and their onset, depth, and duration can vary. They are associated with cord compression, which can reduce blood flow to the fetus during contractions. Other options are as follows:
Choice B: Late decelerations are indicative of uteroplacental insufficiency and are not related to umbilical cord problems.
Choice C: Accelerations are reassuring and suggest a responsive, healthy fetus.
Choice D: Early decelerations are usually benign and result from head compression during contractions, not umbilical cord issues.
Correct Answer is C
Explanation
A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.
B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.
C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.
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