A client has been admitted to the labor and delivery suite for induction of labor for post-term pregnancy. Misoprostol (Cytotec) has been inserted. Which of the following findings would warrant stopping the Cytotec treatment?

Contraction frequency of 1 minute.

Cervix is 50% effaced.

Maternal respiratory rate of 24.

Fetal heart baseline of 150.

Answer and Explanation

The Correct Answer is A

A. Contraction frequency of 1 minute. Misoprostol (Cytotec) is used for cervical ripening, but excessive uterine contractions (tachysystole), defined as more than five contractions in 10 minutes, can lead to fetal distress and uterine rupture. If contractions are occurring every minute, this indicates hyperstimulation, requiring immediate discontinuation of the medication and possible intervention with tocolytics to relax the uterus.

B. Cervix is 50% effaced. Cervical effacement is a normal part of labor progression and does not indicate a need to stop Cytotec treatment. Misoprostol is intended to help soften and ripen the cervix, and 50% effacement suggests the cervix is responding appropriately.

C. Maternal respiratory rate of 24. A respiratory rate of 24 breaths per minute is within the upper normal range for pregnancy due to increased metabolic demands. It does not indicate an adverse reaction to misoprostol or warrant discontinuation of treatment.

D. Fetal heart baseline of 150. A fetal heart rate of 150 beats per minute is within the normal range of 110-160 bpm and does not indicate fetal distress. There is no reason to stop Cytotec based on this finding.

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Correct Answer is B

Explanation

A. Weight gain of 4 pounds in a month. A weight gain of 4 pounds in a month is within the expected range for pregnancy, especially in the third trimester. While rapid or excessive weight gain could indicate fluid retention and worsening heart failure, this amount alone is not immediately concerning.

B. Dyspnea with walking. Dyspnea on exertion in a pregnant woman with congestive heart disease is a serious concern. It may indicate pulmonary congestion, worsening heart failure, or reduced cardiac output. Any increasing shortness of breath, especially with minimal activity, should be reported immediately to prevent complications like pulmonary edema or decompensated heart failure.

C. Presence of striae gravidarum. Striae gravidarum (stretch marks) are a normal skin change in pregnancy due to rapid growth and stretching of the skin. They are not related to congestive heart disease and do not require reporting.

D. Patellar reflexes of +2. A +2 deep tendon reflex (DTR) is normal and does not indicate worsening cardiac status. Reflex abnormalities are more relevant in conditions such as preeclampsia, where hyperreflexia can signal worsening disease, but they are not a concern in heart disease.

A. Frequent monitoring of vital signs B. Assisting with a blood patch procedure C. Correct Administration of oral analgesics D. Keeping the head of bed elevated at all times

Correct Answer is ["A","B","C"]

Explanation

A. Frequent monitoring of vital signs. A post-dural puncture headache (PDPH) can occur after epidural anesthesia due to leakage of cerebrospinal fluid (CSF). Monitoring vital signs, particularly blood pressure and heart rate, helps assess for hypotension, fluid balance, and overall neurological status.

B. Assisting with a blood patch procedure. An epidural blood patch is the most effective treatment for a severe post-dural puncture headache. This procedure involves injecting the patient’s own blood into the epidural space to seal the CSF leak and relieve symptoms. The nurse should prepare for the procedure and educate the patient about it.

C. Administration of oral analgesics. Oral analgesics, such as acetaminophen or ibuprofen, are used to relieve mild to moderate headache symptoms. However, they may not be fully effective for a severe PDPH and are often used as supportive therapy along with other interventions.

D. Keeping the head of bed elevated at all times. Lying flat, rather than elevating the head of the bed, is actually recommended to help reduce CSF leakage and alleviate headache symptoms. Keeping the head elevated may worsen the headache by increasing CSF pressure changes.

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A client has been admitted to the labor and delivery suite for induction of labor for post-term pregnancy. Misoprostol (Cytotec) has been inserted. Which of the following findings would warrant stopping the Cytotec treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman with a history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary health care practitioner?

Correct Answer is B

Explanation

After delivering a healthy baby boy with epidural anesthesia, a woman on the after-birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

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