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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Misoprostol is a synthetic prostaglandin E1 (PGE1) analog that can induce uterine contractions, increasing the risk of a spontaneous miscarriage, particularly in early pregnancy.

Choice B rationale

Misoprostol is not known to increase the risk of preeclampsia. Preeclampsia involves high blood pressure and potential damage to other organ systems, typically appearing after 20 weeks of pregnancy.

Choice C rationale

Misoprostol does have an effect on the unborn child due to its ability to cause uterine contractions and cervical ripening, potentially leading to miscarriage.

Choice D rationale

Misoprostol is not associated with an increased risk of postpartum hemorrhaging after delivery. It is often used to manage postpartum hemorrhage by promoting uterine contractions.

A. Explain that heartburn is a common discomfort. B. Ask if blurred vision and headache have occurred. C. Check urine for presence of glucose and ketones. D. Instruct the client to take an antacid as needed.

Correct Answer is B

Explanation

Choice A rationale

While heartburn is common during pregnancy due to hormonal changes and pressure from the growing uterus, the presence of 3+ bilateral pitting pedal edema raises concerns. This symptom could indicate a more serious condition, such as preeclampsia, and should not be dismissed as a normal discomfort.

Choice B rationale

Asking if blurred vision and headache have occurred is essential because these symptoms, along with significant edema, are indicators of preeclampsia. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and damage to other organ systems, often requiring immediate medical attention.

Choice C rationale

Checking urine for glucose and ketones is relevant for assessing gestational diabetes but does not address the immediate concern of preeclampsia. The symptoms of edema and possible preeclampsia should be prioritized over concerns of gestational diabetes.

Choice D rationale

Instructing the client to take an antacid for heartburn does not address the critical issue of significant edema. While heartburn relief is important, the symptoms of edema need immediate evaluation to rule out preeclampsia or other complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.How should the nurse respond?

Correct Answer is A

Explanation

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes.The nurse observes several shallow, small vesicles on her pubis, labia, and perineum.The nurse should recognize the client is exhibiting symptoms of which condition?

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse prepares to initiate magnesium sulfate therapy for the client. What is the priority nursing action?

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)

The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.

The nurse is performing a newborn assessment.Which symptom, if present in a newborn, would indicate respiratory distress?

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?