A primipara client at 42 weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75-second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20-second duration. Which intervention should the nurse implement?
Notify the nursery about the client’s response.
Restart oxytocin infusion rate per protocol.
Stop oxygen per cannula.
Check for clonus in both feet.
The Correct Answer is B
Choice A rationale
Notifying the nursery about the client’s response is not an immediate intervention. It is more important to manage uterine contractions and fetal oxygenation before informing other departments about the client's condition.
Choice B rationale
Restarting the oxytocin infusion rate per protocol is necessary to resume labor induction. Oxytocin increases uterine contractions, promoting cervical dilation and progression of labor. Continuous monitoring is required to adjust the dosage.
Choice C rationale
Stopping oxygen per cannula is not recommended if fetal distress is present. Oxygen supplementation ensures adequate fetal oxygenation during uterine contractions, reducing the risk of hypoxia and related complications.
Choice D rationale
Checking for clonus in both feet is not relevant to the current scenario. Clonus is a neurological sign indicating hyperreflexia, often unrelated to labor management. The focus should be on managing uterine contractions and fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Confirming Rh and Coombs status is essential for Rho(D) immunoglobulin administration, but it is not the immediate priority during acute bleeding as it does not directly address maternal or fetal distress.
Choice B rationale
Performing a sterile vaginal examination could potentially worsen bleeding if placental abruption or previa is present, making it a less safe option. The immediate concern is to assess fetal and maternal well-being.
Choice C rationale
Assessing the fetal heart rate and contraction pattern provides critical information on the fetus's condition and helps determine whether there is fetal distress, which is vital in deciding the urgency of interventions.
Choice D rationale
Determining fetal position using Leopold maneuvers is not a priority during acute bleeding episodes since it does not provide immediate information on fetal well-being or the cause of the bleeding.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Routine pediatric check-ups typically occur 2–4 weeks after birth. This allows the pediatrician to monitor the baby's growth, development, and overall health, including weight gain and feeding patterns.
Choice B rationale
Home bilirubin lights are recommended for treating neonatal jaundice, a common condition in newborns. Bilirubin lights help lower bilirubin levels in the baby's blood, preventing potential complications like kernicterus.
Choice C rationale
Postpartum obstetrician appointments are usually scheduled 6–8 weeks after delivery to assess the mother's recovery, address any postpartum concerns, and provide guidance on contraception and future pregnancies.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.