A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse's initial action?

Stop the oxytocin infusion.

Turn her on her left side and reassess the contractions.

Continue the infusion and report the findings to the physician.

Administer oxygen by mask.

Answer and Explanation

The Correct Answer is A

A. Stop the oxytocin infusion: Oxytocin should be stopped immediately to prevent hyperstimulation of the uterus, which can lead to fetal distress or uterine rupture.

B. Turn her on her left side and reassess the contractions: While this position can improve fetal oxygenation, it does not address the root cause, which is uterine hyperstimulation.

C. Continue the infusion and report the findings to the physician: Unsafe action as uterine hyperstimulation poses significant risks.

D. Administer oxygen by mask: Oxygen may be needed but is not the priority. Stopping the oxytocin is the first step.

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Correct Answer is A

Explanation

A. Fundal consistency: Oxytocin promotes uterine contractions to prevent postpartum hemorrhage; a firm, contracted fundus indicates effectiveness.

B. Urinary output: While important to monitor postpartum, it does not directly evaluate oxytocin effectiveness.

C. Blood pressure: Oxytocin can cause changes in blood pressure, but this is not a primary measure of effectiveness.

D. Pulse rate: A rising pulse rate could indicate blood loss but is not a direct measure of oxytocin’s effectiveness.

A. “A repeat cesarean section would be safer for both you and your day.” B. “The primary consideration is what type of incision you had.” C. “There are so many variables that you'll have to ask your provider.” D. “It's too soon for you to be worrying about that now.”

Correct Answer is B

Explanation

A. "A repeat cesarean section would be safer for both you and your baby.": VBAC is often safe, depending on the uterine incision type. A blanket statement about safety is inaccurate.

B. "The primary consideration is what type of incision you had.": The type of uterine incision (e.g., low transverse) determines VBAC eligibility due to the risk of uterine rupture.

C. "There are so many variables that you'll have to ask your provider.": While consultation with a provider is important, this response lacks educational value.

D. "It's too soon for you to be worrying about that now.": This response dismisses the client’s concerns and is non-therapeutic.

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A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse's initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate effectiveness of this medication?

Correct Answer is A

Explanation

A nurse is caring for a client who wants to know it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate?

Correct Answer is B

Explanation

The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate?

What does the nurse note when measuring the frequency of a laboring woman’s contractions?

The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief?

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take?