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 C
Explanation
A. Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B. Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C. Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D. Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.
Correct Answer is D
Explanation
Choice A: Fetal lung maturity is not assessed through maternal serum alphafetoprotein testing. It is usually evaluated through tests such as amniocentesis or specialized ultrasound examinations closer to the third trimester.
Choice B: The maternal serum alphafetoprotein test specifically screens for certain birth defects and genetic conditions in the fetus, rather than general signs of physical and physiological
wellbeing.
Choice C: The maternal serum alphafetoprotein test is not used to identify Rh incompatibility. Rh incompatibility is determined through blood tests that assess the Rh factor of the mother's blood and the Rh status of the baby.
Choice D: The maternal serum alphafetoprotein test is a blood screening test that can identify neural tube defects (such as spina bifida) and chromosomal abnormalities (such as Down syndrome) in the fetus. The test measures the levels of alphafetoprotein in the mother's blood, and abnormal levels may indicate the need for further diagnostic testing.
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