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 D

Explanation

The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.

This is a serious side effect that needs to be monitored closely by the nurse.

Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.

The Babinski reflex is a normal response in infants, but abnormal in adults.

It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.

Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.

Choice C is wrong because tetany is not a side effect of magnesium sulfate.

Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.

A. Notify the health care provider. B. Position the patient in a left lateral position. C. Increase the patient’s intravenous rate. D. Provide the patient with oxygen via a face mask.

Correct Answer is B

Explanation

The correct answer is choice B. Position the patient in a left lateral position.This is because late fetal decelerations indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus.By positioning the patient on her left side, the blood flow to the placenta and the fetus is improved.

Choice A is wrong because notifying the health care provider is not the first action that the nurse should take.The nurse should first intervene to correct the cause of fetal distress and then inform the provider.

Choice C is wrong because increasing the patient’s intravenous rate may not help with uteroplacental insufficiency.It may also cause fluid overload or pulmonary edema in the patient.

Choice D is wrong because providing the patient with oxygen via a face mask is not the most effective way to increase fetal oxygenation.Oxygen therapy may be used as an adjunct to other interventions, but it is not sufficient by itself.

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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 is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?

Correct Answer is D

Explanation

The fetal monitor indicates that a patient is having contractions every three to four minutes with late fetal decelerations.Which action should the nurse take first?

Correct Answer is B

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?