The laboring patient is being augmented with oxytocin and is experiencing contractions every 3-4 minutes lasting 60 seconds. The patient's fetal heart rate is ranging from 130-140 beats per minute (BPM) with moderate variability of 6-10 beats per minute. No decelerations are noted. Which action by the nurse is most appropriate?
Insert an internal fetal scalp electrode monitor
Contact the doctor at once and reposition the patient
Document the finding in the patient's medical record
Discontinue the IV fluid containing Pitocin (oxytocin)
The Correct Answer is C
A. Insert an internal fetal scalp electrode monitor. There is no indication for an internal fetal monitor, as the external monitoring shows a reassuring fetal heart rate pattern with moderate variability and no decelerations. Internal monitoring is typically used when external monitoring is inadequate or when fetal distress is suspected.
B. Contact the doctor at once and reposition the patient. There is no fetal distress or abnormal contraction pattern requiring immediate physician intervention. The fetal heart rate is within the normal range (110-160 bpm), and moderate variability indicates adequate oxygenation.
C. Document the finding in the patient's medical record. This is the correct action because the assessment findings indicate a well-oxygenated fetus and a normal labor progression. Contractions every 3-4 minutes lasting 60 seconds are within the expected range for oxytocin augmentation, and no abnormalities are present.
D. Discontinue the IV fluid containing Pitocin (oxytocin). There is no need to stop the oxytocin infusion, as the contraction pattern is appropriate, and there are no signs of uterine tachysystole or fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Right-sided epigastric pain. Epigastric pain, especially on the right side, is a concerning sign of preeclampsia and may indicate liver involvement due to elevated liver enzymes or HELLP syndrome. This symptom should be assessed further as it suggests worsening disease progression.
B. Uterine contractions. Uterine contractions are not a defining feature of preeclampsia. They are more commonly associated with preterm labor rather than hypertension-related complications. While preeclampsia can lead to preterm birth, contractions alone do not confirm or negate the condition.
C. Bright red painless vaginal bleeding. Bright red painless vaginal bleeding is more indicative of placenta previa or another obstetric complication rather than preeclampsia. Preeclampsia primarily presents with hypertension, proteinuria, and systemic symptoms rather than vaginal bleeding.
D. Severe headache. A severe headache is a classic symptom of preeclampsia, often due to elevated blood pressure and cerebral edema. Persistent headaches that do not resolve with usual interventions should be evaluated promptly as they may indicate worsening hypertension or an impending seizure.
E. Visual disturbances. Visual disturbances such as blurred vision, photophobia, or seeing spots are common in preeclampsia and can signal cerebral edema or increased intracranial pressure. This is a significant warning sign requiring immediate assessment.
F. Dull backache. A dull backache is more commonly associated with musculoskeletal strain, labor, or a urinary tract infection rather than preeclampsia. While discomfort can be present in pregnancy, it is not a defining symptom of preeclampsia.
Correct Answer is B
Explanation
A. Quantity of vaginal bleeding. While both placenta previa and abruptio placentae can cause vaginal bleeding, the amount alone does not differentiate between the two conditions. Placenta previa typically causes painless, bright red bleeding, whereas abruptio placentae often presents with concealed or variable bleeding, making quantity an unreliable distinguishing factor.
B. Presence of abdominal pain. Abdominal pain is a key differentiating factor. Placenta previa is characterized by painless vaginal bleeding, while abruptio placentae causes sudden, severe abdominal pain due to placental detachment and uterine muscle irritation. This makes the presence or absence of pain an important assessment finding.
C. Leopold's maneuver results. While Leopold’s maneuvers help determine fetal position and presentation, they do not provide definitive information about the location of the placenta or differentiate between placenta previa and abruptio placentae. Ultrasound is a more reliable diagnostic tool for this purpose.
D. Maternal blood pressure. Although abruptio placentae can lead to hypovolemic shock and blood pressure changes due to hemorrhage, maternal blood pressure alone is not a primary diagnostic criterion for differentiating between the two conditions. Other clinical findings such as pain and ultrasound results are more useful for diagnosis.
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