A client who is receiving oxytocin to augment early labor begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

Alert the charge nurse to the patient's condition.

Reposition the fetal monitor transducers.

Turn off the oxytocin infusion.

Decrease the rate of the oxytocin infusion.

Answer and Explanation

The Correct Answer is C

A. Alert the charge nurse to the patient's condition: While it may be necessary to notify the charge nurse depending on the severity of the situation, the priority action is to address the immediate cause of the tachysystolic or tetanic contractions by turning off the oxytocin.

B. Reposition the fetal monitor transducers: Repositioning the transducers may be helpful for improving the quality of fetal heart rate monitoring but does not address the underlying issue of excessive uterine contractions and fetal distress.

C. Turn off the oxytocin infusion: The first action in response to tachysystolic or tetanic contractions and variable decelerations is to turn off the oxytocin infusion. Overstimulation of the uterus with oxytocin can cause uterine hyperstimulation, leading to fetal distress, and stopping the infusion can help resolve this.

D. Decrease the rate of the oxytocin infusion: Decreasing the oxytocin rate is less effective than completely turning off the infusion in the case of excessive contractions and fetal decelerations. Stopping the infusion entirely addresses the issue more directly.

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Correct Answer is C

Explanation

A. Maternal apical heart rate: While monitoring the maternal heart rate is important, the primary concern in this scenario is the timing of the oxytocin infusion in relation to the onset of bleeding. The time of the infusion helps determine if there is a correlation with the excessive bleeding.

B. Maternal blood pressure: Blood pressure is important for assessing hemodynamic stability, especially in cases of hemorrhage, but the most important immediate information would be related to the timing of the oxytocin infusion, as this could help determine if it is a contributing factor to the bleeding.

C. Time oxytocin infusion completed: The timing of the oxytocin infusion is the most important piece of information to provide. If the bleeding began after the infusion, the healthcare provider can consider oxytocin as a potential cause of uterine atony or other complications.

D. Total amount of oxytocin infused: While the total amount of oxytocin administered is important, the timing of the infusion is more critical in understanding the connection between the oxytocin administration and the onset of bleeding.

A. Artificial rupture of the membranes. B. Administration of antibiotics. C. Amnioinfusion for the baby. D. Administration of oxytocin.

Correct Answer is B

Explanation

A. Artificial rupture of the membranes: While artificial rupture of membranes may be done in some situations, it is not an immediate treatment for a GBS-positive client. The priority is to reduce the risk of infection, which is best achieved with antibiotics.
B. Administration of antibiotics: The most important and immediate treatment for a GBS-positive laboring client is administration of antibiotics, usually penicillin or ampicillin, to reduce the risk of transmitting the infection to the baby during delivery. This is typically given during labor.
C. Amnioinfusion for the baby: Amnioinfusion is a procedure used to relieve umbilical cord compression or meconium aspiration, but it is not indicated for managing GBS infection. Antibiotics are the primary treatment to prevent neonatal infection.
D. Administration of oxytocin: Oxytocin is used to stimulate labor but is not the immediate priority for a GBS-positive client. The focus should be on preventing infection through antibiotic administration, not on initiating or enhancing labor.

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A client who is receiving oxytocin to augment early labor begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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