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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Soft and not palpable: Immediately after delivery, the fundus should be firm and palpable. A soft, non-palpable fundus may indicate uterine atony, which is a serious condition that could lead to hemorrhage and requires immediate intervention.
B. Above the umbilicus: Immediately after delivery, the fundus is typically at or just below the umbilicus. If it is above the umbilicus, it could indicate uterine distension, a retained placenta, or excessive bleeding that needs to be addressed.
C. At or below the umbilicus: The fundus is expected to be firm and palpable at or just below the umbilicus immediately after delivery. This position reflects normal uterine contraction as the uterus begins to return to its pre-pregnancy size.
D. To the left or right of the umbilicus: The fundus should be midline after delivery. A deviation to the left or right may suggest a full bladder or uterine displacement, which can interfere with uterine contraction and increase the risk of bleeding.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D","dropdown-group-3":"D"}
Explanation
Rationale for Correct Choices:
- Hypoxia: Abnormal fetal heart rate (FHR) patterns, especially decelerations, suggest that the fetus may not be receiving enough oxygen, leading to hypoxia. This condition requires prompt intervention to improve fetal oxygenation.
- Hypoxemia: Similar to hypoxia, hypoxemia refers to a low level of oxygen in the blood. If the abnormal FHR patterns continue, they may indicate that the fetus is not getting enough oxygen, leading to hypoxemia, which can result in further complications.
- Acidemia: A lack of oxygen (hypoxia and hypoxemia) can lead to acidemia, where there is an increase in the acidity of the fetal blood. This occurs when the fetus begins to build up metabolic acids, a sign of inadequate oxygenation and the body's inability to maintain proper pH balance.
Rationale for Incorrect Choices:
- Maternal hypotension: While maternal hypotension can affect fetal heart rate, it is not directly related to abnormal FHR patterns unless the hypotension is severe. The patient data provided does not indicate that maternal hypotension is the cause of the abnormal FHR pattern in this case.
- Hypoglycemia: While hypoglycemia can cause fetal distress, it is less likely to result in the specific FHR pattern here (decelerations). The cause of the decelerations appears to be more related to oxygenation issues rather than glucose imbalance.
- Meconium stool: Meconium passage can be a sign of fetal distress, but it is not a direct consequence of abnormal FHR patterns. The focus here is on the potential for oxygen deprivation and metabolic disturbances like acidemia and hypoxia.
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