While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
Maternal pulse rate of 100 bpm.
Maternal blood pressure of 120/70 mm Hg.
Decrease in intensity of uterine contractions.
Persistent fetal bradycardia below 100 bpm.
The Correct Answer is D
The correct answer is: d. Persistent fetal bradycardia below 100 bpm.
Choice A: Maternal pulse rate of 100 bpm
A maternal pulse rate of 100 beats per minute (bpm) is slightly elevated but not uncommon during labor due to the physical exertion and stress involved. The normal range for an adult’s resting heart rate is typically between 60 and 100 bpm. While it is important to monitor the maternal pulse, it is not an immediate cause for concern unless accompanied by other symptoms such as hypotension, chest pain, or signs of distress.
Choice B: Maternal blood pressure of 120/70 mm Hg
A maternal blood pressure of 120/70 mm Hg is within the normal range. Normal blood pressure for adults is generally considered to be around 120/80 mm Hg. This reading indicates that the mother is maintaining stable blood pressure during labor, which is a positive sign. Therefore, this does not require immediate reporting to the physician.
Choice C: Decrease in intensity of uterine contractions
A decrease in the intensity of uterine contractions can be concerning as it may indicate ineffective labor, which could prolong the delivery process. However, this is typically managed by adjusting oxytocin levels or other interventions and does not require immediate reporting unless it leads to other complications such as fetal distress.
Choice D: Persistent fetal bradycardia below 100 bpm
Persistent fetal bradycardia below 100 bpm is a significant concern and should be immediately reported to the physician. Normal fetal heart rate ranges from 110 to 160 bpm. Bradycardia, defined as a heart rate below 110 bpm, can indicate fetal distress, hypoxia, or other complications that may require urgent intervention to ensure the safety of the fetus. Persistent bradycardia, especially below 100 bpm, necessitates immediate medical attention to assess and address the underlying cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Measuring urinary output. This is not the priority nursing care associated with an oxytocin infusion, because urinary output is not directly affected by oxytocin. Urinary output may be affected by other factors, such as fluid intake, dehydration, or kidney function, but these are not related to oxytocin administration. • Choice B reason:
Evaluating cervical dilation. This is also not the priority nursing care associated with an oxytocin infusion, because cervical dilation is a result of uterine contractions, not oxytocin itself. Oxytocin is used to stimulate or augment uterine contractions, but it does not cause cervical dilation directly. Cervical dilation is important to monitor during labor, but it is not the main focus of oxytocin infusion. • Choice C reason:
Increasing infusion rate every 30 minutes. This is not the priority nursing care associated with an oxytocin infusion, because increasing the infusion rate every 30 minutes is not a standard protocol for oxytocin administration. The infusion rate should be adjusted according to the patient's response and the provider's orders, but not arbitrarily or routinely. Increasing the infusion rate too quickly or too often can cause hyperstimulation of the uterus, which can be dangerous for both the mother and the fetus.
• Choice D reason:
Monitoring uterine response. This is the correct answer and the priority nursing care associated with an oxytocin infusion, because oxytocin can cause excessive or prolonged uterine contractions, which can lead to fetal distress, uterine rupture, or placental abruption. Therefore, the nurse must monitor the frequency, duration, and intensity of uterine contractions, as well as the fetal heart rate and blood pressure, to ensure that oxytocin is having the desired effect and not causing any adverse outcomes.
Correct Answer is A
Explanation
Choice A reason:
This is the best response because it shows that the nurse is providing nonpharmacological pain relief measures and supporting the client's coping mechanisms. Breathing and imagery techniques can help the client relax and focus on something other than the pain. Moaning, screaming, and vocalizing are normal and acceptable ways of expressing pain during labor, and the nurse should not try to suppress them.
Choice B reason:
This is not the best response because it does not address the husband's concern or offer any intervention for the client's pain. Asking the client to rate her pain on a scale of 0 to 10 is a subjective assessment tool that may not reflect the true intensity of her pain. Furthermore, it may be difficult for the client to answer this question while she is in the second stage of labor.
Choice C reason:
This is not the best response because it may not be feasible or appropriate to administer more pain medication to the client in the second stage of labor. The obstetrician may not be available to evaluate the client's pain, and increasing the dose of pain medication may have adverse effects on the client and the fetus, such as respiratory depression, hypotension, and decreased uterine contractility.
Choice D reason:
This is not the best response because it does not acknowledge the husband's feelings or provide any comfort or education for him. Reassuring him that his wife will be fine may sound dismissive and insensitive, and offering to stay with her while he takes a walk may imply that he is not needed or wanted in the birthing room. The nurse should involve the husband in the care of his wife and explain to him what is happening and what to expect during labor.
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