For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
A woman in early labor with contractions every 5 minutes lasting 40 seconds each.
A woman in active labor with contractions every 30 minutes lasting 60 seconds each.
A woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each.
A woman in transition with contractions every 1.5 minutes lasting 95 seconds each.
The Correct Answer is D
Choice A reason:
The woman in early labor with contractions every 5 minutes lasting 40 seconds each does not require the immediate discontinuation of the oxytocin (Pitocin) infusion. Early labor is characterized by mild and infrequent contractions as the cervix begins to dilate and efface. Choice B reason:
The woman in active labor with contractions every 30 minutes lasting 60 seconds each also does not warrant immediate discontinuation of the oxytocin (Pitocin) infusion. Active labor typically involves regular and stronger contractions as the cervix continues to dilate and the baby progresses downward.
Choice C reason:
The woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each does not require immediate cessation of the oxytocin (Pitocin) infusion. These contractions are within the expected range for active labor and may be considered normal.
Choice D reason:
The woman in transition with contractions every 1.5 minutes lasting 95 seconds each should have the oxytocin (Pitocin) infusion discontinued immediately. Transition is the most intense phase of labor, characterized by rapid and strong contractions as the cervix completes dilation. Prolonged and frequent contractions during this phase can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. Discontinuing the oxytocin infusion is necessary to reduce the intensity and frequency of contractions, ensuring better fetal well-being during this critical phase of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
If the client reports frequent uterine contractions , it is not indicative of a distended bladder. Postpartum uterine contractions are normal and necessary to help the uterus return to its pre-pregnancy size.
Choice B reason:
The fundus (the top portion of the uterus being palpable to the right of the midline suggests a distended bladder. A full bladder can displace the uterus, causing the fundus to deviate from the midline.
Choice C reason:
Having less than 2.5 cm of rubra lochia on a perineal pad is related to the amount of vaginal discharge after birth and does not provide information about bladder distention.
Choice D reason:
The client's report of increased thirst may indicate dehydration or the body's response to fluid loss during childbirth but is not directly related to bladder distention.
Correct Answer is D
Explanation
The correct answer is choice D. Announcement of the delivery.
Choice A reason:
Support thermoregulation is a priority in nursing care of the newborn immediately after birth. Newborns are at risk of hypothermia because they have a large surface area to body mass ratio, thin skin, and limited subcutaneous fat. To prevent heat loss, newborns should be dried thoroughly, placed skin-to-skin with the mother, and covered with warm blankets.
Choice B reason:
Identifying the infant is a priority nursing care of the newborn immediately after birth. Newborns should be identified with identification bands that match those of the mother and father or significant other. This helps prevent errors in infant identification and ensures safety and security.
Choice C reason:
Promoting normal respirations is a priority nursing care of the newborn immediately after birth. Newborns need to establish effective breathing patterns to ensure adequate oxygenation and prevent complications such as respiratory distress syndrome or meconium aspiration syndrome. To promote normal respirations, newborns should be suctioned gently to clear the airway, stimulated to cry, and assessed for signs of distress.
Choice D reason:
Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
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