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?
Stop oxygen per cannula.
Check for clonus in both feet.
Notify nursery about the client's response.
Restart oxytocin infusion rate per protocol.
The Correct Answer is D
Stopping oxygen per cannula after uterine hyperstimulation and subsequent contraction reduction is not appropriate. Oxygen should be continued to ensure fetal oxygenation, particularly after a period of stress caused by frequent contractions. Discontinuing oxygen too soon may compromise fetal well-being.
Choice B rationale
Checking for clonus in both feet is unrelated to the management of uterine contractions post-oxytocin administration. Clonus assessment is used in evaluating neuromuscular function, often in conditions such as preeclampsia, but not for monitoring uterine activity or response to oxytocin.
Choice C rationale
Notifying the nursery about the client's response is important for continuity of care but does not address the immediate need to manage the uterine contractions. The primary focus should be on stabilizing uterine activity before updating other departments.
Choice D rationale
Restarting the oxytocin infusion rate per protocol is the correct intervention after ensuring that the contractions have reduced to a safe frequency and duration. This approach helps to maintain labor progress while minimizing the risk of hyperstimulation and fetal distress. The nurse should follow the hospital's guidelines for oxytocin titration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
- Blood pressure: 170/98 mm Hg: Abnormal. A blood pressure reading of 170/98 mm Hg is high, especially in the context of pregnancy, where it may indicate gestational hypertension or the potential for preeclampsia. This needs to be monitored closely.
- Pain rating: 5/10 with contractions: Normal. A pain rating of 5/10 is typical during labor, especially at this stage of dilation (4 cm). Pain management can be adjusted based on the client's preference and progress.
- Variable decelerations: 20 seconds: Normal. Occasional variable decelerations (drops in fetal heart rate that last for less than 30 seconds) can occur during labor, often due to umbilical cord compression. As long as the decelerations are brief and not repetitive or severe, they are typically not concerning.
- Magnesium sulfate infusion ongoing: Normal. The magnesium sulfate infusion is prescribed to manage potential complications, likely to prevent preterm labor or to prevent seizures in the event of preeclampsia. Its ongoing use is appropriate for this client at this stage.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Standard precautions should always be used to prevent the transmission of infections. This includes wearing gloves, gowns, and masks when necessary to protect both the healthcare provider and the patient.
Choice B rationale
Antiviral medication is critical for an HIV-positive mother in labor to reduce the risk of vertical transmission of the virus to the newborn. Intravenous administration ensures rapid delivery and effective drug levels.
Choice C rationale
Droplet precautions are not necessary for HIV as the virus is not transmitted via droplets. It is primarily transmitted through blood, sexual contact, and from mother to child during childbirth or breastfeeding.
Choice D rationale
Bottle-feeding is encouraged for HIV-positive mothers to prevent postnatal transmission of the virus through breast milk. Breastfeeding can increase the risk of the infant contracting HIV.
Choice E rationale
Negative pressure rooms are used for airborne diseases like tuberculosis, not for HIV. HIV is not airborne, so standard precautions suffice.
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