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. Arrange for her to meet the staff who will be caring for her during labor and delivery.This measure can help reduce the anxiety and fear of the unknown that a primigravida may have in the last month of pregnancy.Meeting the staff can also help establish rapport and trust, which are essential for a positive birth experience.

Choice A is wrong because an increase in fetal activity does not necessarily require an increase in the need to rest.

Fetal activity is normal and expected, and the mother should monitor it regularly.Resting may help with some discomforts of pregnancy, but it is not directly related to fetal activity.

Choice B is wrong because back labor is not likely for a primigravida with an uncomplicated pregnancy.

Back labor occurs when the fetus is in an occiput posterior position, which puts pressure on the mother’s spine and causes intense pain in the lower back.This position is more common in multiparous women than primigravidas.

Choice D is wrong because testing urine for glucose is not a routine measure for a primigravida with an uncomplicated pregnancy.

Urine glucose testing is done for women who have gestational diabetes or are at risk of developing it.It is not necessary for women who have normal blood glucose levels.

A. Sustained uterine hypertonicity. B. Strong uterine contractions every 3-4 minutes. C. Bile-colored vomitus. D. Fetal heart rate acceleration with fetal activity.

Correct Answer is A

Explanation

This means that the uterus is constantly contracted and does not relax between contractions.This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae.Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.

Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.

Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.

Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby.Placental abruption can cause fetal distress and a decrease in fetal heart rate.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 16-year-old primigravida who is in the last month of an uncomplicated pregnancy. Which measure is most appropriate to include in the patient’s plan of care?

Correct Answer is C

Explanation

A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun. A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

Correct Answer is A

Explanation

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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?