Intrauterine resuscitation for an evolving category II or category III tracing includes (Select all that apply):
Go to break
Apply 100% non-rebreather mask
Give an IV fluid bolus
Reposition the mother
Increase the oxytocin drip
Decrease or stop the oxytocin
Correct Answer : B,C,D,F
Choice A: Go to break is not an appropriate action, as it can delay the necessary interventions and compromise the fetal well-beinG. The nurse should stay with the mother and monitor the fetal heart rate and the uterine activity continuously.
Choice B: Apply 100% non-rebreather mask is an appropriate action, as it can increase the maternal oxygenation and improve the fetal oxygen delivery. The nurse should place a mask with a reservoir bag over the mother's nose and mouth and adjust the flow rate to 10 to 15 L/min.
Choice C: Give an IV fluid bolus is an appropriate action, as it can increase the maternal blood volume and improve the uterine perfusion. The nurse should administer 500 to 1000 mL of isotonic crystalloid solution rapidly through a large-bore IV catheter.
Choice D: Reposition the mother is an appropriate action, as it can relieve the uterine or cord compression and improve the fetal circulation. The nurse should turn the mother to the left or right lateral position or place her in a knee-chest position.
Choice E: Increase the oxytocin drip is not an appropriate action, as it can increase the uterine contractions and reduce the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
Choice F: Decrease or stop the oxytocin is an appropriate action, as it can decrease the uterine contractions and increase the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A: Elevated liver function tests indicate liver damage, which is a complication of preeclampsia with severe features.
Choice B: Unremitting headache is a sign of increased intracranial pressure, which can result from cerebral edema or hemorrhage caused by preeclampsia with severe features.
Choice C: Rising protein in sequential 24-hour urine reflects the degree of glomerular damage and renal impairment caused by preeclampsia with severe features.
Choice D: Increased urine output is not a sign of preeclampsia with severe features. In fact, oliguria (decreased urine output) may occur due to reduced renal perfusion and acute kidney injury.
Choice E: Pain in the left upper quadrant is a sign of splenic rupture or subcapsular hematoma, which are rare but life-threatening complications of preeclampsia with severe features.
Choice F: BP > 160/110 is one of the diagnostic criteria for preeclampsia with severe features, as it indicates severe hypertension and increased risk of maternal and fetal complications.
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