A client G3 T2 P0 A0 L2 pregnant at 37 weeks gestation has a chief complaint of contractions which began 3 hours ago. Vaginal exam on admission was 6 cm/70%/-2. Fetal heart baseline is 145 bpm with moderate variability and accelerations. Uterine contractions are 60 minutes apart, lasting 50 seconds. The nurse performs another cervical exam 2 hours later and reports no change. What orders would the nurse anticipate?
Continue to monitor the client
Obtain an order from the health care provider to start oxytocin
Perform a vaginal exam
Administer an enema
The Correct Answer is B
Choice A reason: Continuing to monitor without intervention is not appropriate because the client has had no cervical change over 2 hours, indicating ineffective labor. Intervention is needed to augment contractions.
Choice B reason: Oxytocin is the correct intervention. It stimulates uterine contractions, helping to progress cervical dilation and labor. Since contractions are infrequent (60 minutes apart) and ineffective, oxytocin administration is indicated to promote active labor.
Choice C reason: Performing another vaginal exam alone will not address the lack of progress. Vaginal exams are useful for assessment but do not stimulate labor.
Choice D reason: Administering an enema is outdated and not recommended for labor augmentation. It does not promote cervical change and may cause discomfort.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering the highest effective dose is unsafe. Oxytocin must be titrated carefully because excessive dosing can cause uterine tachysystole, fetal distress, or uterine rupture.
Choice B reason: Intermittent monitoring is not appropriate with oxytocin infusion. Continuous monitoring is required because oxytocin increases risk of fetal compromise and uterine hyperstimulation.
Choice C reason: Administering the dose as ordered is the correct consideration. Nurses must follow prescribed protocols, titrate carefully, and monitor maternal-fetal response. This ensures safe induction while minimizing risks.
Choice D reason: Discontinuing oxytocin for reassuring fetal heart patterns is incorrect. Oxytocin should be discontinued if fetal heart patterns become non-reassuring or if uterine tachysystole occurs, not when patterns are reassuring.
Correct Answer is D
Explanation
Choice A reason: Joint relaxation is not permanent. Ligamentous laxity resolves as hormone levels normalize postpartum.
Choice B reason: Joints and ligaments do not return to normal within 1–2 weeks. The process of involution and hormonal stabilization takes longer.
Choice C reason: Breastfeeding does not prolong ligamentous laxity. Relaxin levels decrease after delivery regardless of breastfeeding status.
Choice D reason: Joints and ligaments typically return to their pre-pregnancy state within 6–8 weeks postpartum as relaxin levels decline and connective tissues regain tone. This is the correct response.
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