A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin.
Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?

Document the findings.

Pause the oxytocin infusion.

Raise the head of the patient’s bed 30 degrees.

Notify the health care provider.

Answer and Explanation

The Correct Answer is B

This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.

Choice A is wrong because documenting the findings is not a priority action in this situation.

The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.

Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.

It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.

Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.

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Correct Answer is C

Explanation

The correct answer is choice C. The patient should palpate her breasts using the padded sections of her fingers.This is the recommended technique for breast self-examination, as it allows the patient to feel any changes or lumps in the breast tissue.

Choice A is wrong because the patient should perform breast self-examination at the same time each month, preferably a few days after the menstrual period ends when the breasts are less likely to be swollen or tender.

Choice B is wrong because the patient should not assume that any lumps that are present in both breasts are normal.Some breast cancers can affect both breasts, and any new or unusual lumps should be reported to a doctor.

Choice D is wrong because the patient should look at her breasts while standing in front of the mirror with her arms at her sides, raised overhead, and pressed firmly on her hips.She should also look for any changes in the shape, size, color, or texture of her breasts and nipples.

A. Observe the patient for vaginal discharge of bright red blood. B. Assess the patient’s vaginal tone. C. Massage the patient’s perineum. D. Apply petrolatum to the patient’s perineum.

Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

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A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin. Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who is attending a family planning clinic is instructed in breast self-examination by a nurse. Which statement by the patient would indicate that she understands the instructions?

Correct Answer is C

Explanation

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?

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A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

A patient who is 38 weeks pregnant and has tested positive for a chlamydial infection asks the nurse to discuss the baby's risk of becoming infected.Which information should the nurse include in discussion with the patient?

A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

A patient who is 42 weeks pregnant is admitted to the hospital in active labor.The patient is upset and says to the nurse, "I haven't felt the baby move for about three or four hours." The fetal heart rate is ranging between 136 and 143. Which action should the nurse take?

A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin.
Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?