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.
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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Related Questions
Correct Answer is D
Explanation
A. Promoting delivery of the placenta: The placenta is delivered after the infant, making this a lower priority.
B. Preventing the perineum from tearing: While important, protecting the infant during birth takes precedence.
C. Cutting the umbilical cord: Cutting the cord occurs after delivery and is not the immediate priority.
D. Supporting the infant during the birth: The safety of the infant during rapid delivery is the top priority.
Correct Answer is D
Explanation
A. The cervix is dilated 5 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines: The dilation is incorrectly identified as 5 cm.
B. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines: Effacement is expressed as a percentage, not in centimeters.
C. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines: Effacement and station are incorrectly interpreted.
D. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines: This interpretation is accurate, matching the documented findings.
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