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 []
Explanation
Rationale for correct condition: Hypoglycemia in neonates can present with jitteriness, low body temperature, and poor feeding. Normal blood glucose levels for neonates range from 40-60 mg/dL. The Ballard maturity rating of 37 weeks indicates that the neonate may have an immature glucose metabolism. Early recognition and treatment are crucial to prevent complications.
Rationale for correct actions:
- Giving dextrose solution orally quickly increases blood glucose levels. This provides an immediate source of glucose to the neonate.
- Performing a heel stick for blood glucose testing allows for accurate monitoring of glucose levels. Continuous assessment ensures timely intervention.
Rationale for correct parameters:
- Blood glucose levels: Monitoring ensures that the neonate maintains normal glucose levels (40-60 mg/dL). This helps prevent hypoglycemia-related complications.
- Temperature: Neonates with hypoglycemia often have low body temperature. Monitoring temperature aids in detecting and addressing hypothermia.
Rationale for incorrect conditions:
- Altered respiratory function: The neonate has normal respiratory rate and heart rate.
- Thermoregulation: Although temperature is low, the jitteriness is more indicative of hypoglycemia.
- Sepsis: No signs of infection such as fever or elevated white blood cell count are present.
Rationale for incorrect actions:
- Provide manual breaths with a bag-valve mask: Not necessary as the neonate's respiratory rate is normal.
- Administer intravenous antibiotics: No signs of infection or sepsis.
- Place the neonate under a radiant warmer: This addresses temperature but not blood glucose levels.
Rationale for incorrect parameters:
- Respiratory rate: Normal, does not indicate hypoglycemia.
- Oxygen saturation: No signs of respiratory distress.
- Bilirubin levels: Not relevant to the current symptoms.
Correct Answer is ["B","D","F","G"]
Explanation
Choice B rationale
Proteinuria indicates preeclampsia, which involves increased glomerular permeability due to endothelial damage. Normal protein in urine is <150 mg/day.
Choice F rationale
Hyperreflexia can be a sign of CNS irritability in preeclampsia, which can lead to seizures if untreated. Normal reflexes are 2+.
Choice G rationale
Assessing lung sounds is critical as pulmonary edema can develop in severe preeclampsia due to increased capillary permeability. Normal breath sounds are clear and equal bilaterally.
Choice D rationale
A vision test helps assess for visual disturbances due to cerebral edema or optic nerve involvement in preeclampsia. Normal visual acuity is 20/20.
Choice A rationale
Hemoglobin assessment could indicate anemia, but it does not specifically address preeclampsia symptoms. Normal hemoglobin is 12-16 g/dL for women.
Choice C rationale
Perineal assessment checks for infection or hematoma but is less likely to explain systemic symptoms like headache and dizziness.
Choice E rationale
Skin turgor assesses hydration status, but dehydration is less likely to explain severe headache, dizziness, and visual disturbances. Normal skin turgor is immediate recoil.
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