A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of labor.

The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction.

What action should the nurse implement at this time?

Administer 10 L of oxygen via face mask.

Place the client on her left side.

Discontinue the oxytocin (Pitocin) infusion.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

Discontinue the oxytocin (Pitocin) infusion. This is because the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction indicate a late deceleration, which is a sign of fetal hypoxia. Oxytocin is a drug that stimulates uterine contractions and can cause uterine hyperstimulation, which reduces blood flow to the placenta and the fetus. By stopping the oxytocin infusion, the nurse can reduce the frequency and intensity of contractions and improve fetal oxygenation.

Choice A is wrong because administering oxygen via facemask may not be enough to reverse fetal hypoxia if oxytocin is still being infused. Choice B is wrong because placing the client on her left side may improve maternal blood flow to the placenta, but it will not reduce the effects of oxytocin on uterine activity.

Choice D is wrong because notifying the healthcare provider is not the most urgent action at this time. The nurse should first discontinue the oxytocin infusion and then notify the healthcare provider.

Normal ranges for FHR are 110 to 160 beats per minute, with a baseline variability of 6 to 25 beats per minute.

Normal ranges for uterine contractions are 2 to 5 contractions in 10 minutes, lasting

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Correct Answer is B

Explanation

Encouraging frequent breastfeeding.

This is because breastfeeding provides glucose to the newborn baby, which can help prevent or treat hypoglycemia (low blood sugar).Hypoglycemia can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.

Choice A is wrong because administering IV insulin would lower the blood sugar level even more, which could be dangerous for the baby.

Choice C is wrong because monitoring blood pressure is not directly related to hypoglycemia.

Blood pressure may be affected by other factors such as stress, infection, or dehydration.

Choice D is wrong because administering a hypertonic saline solution would increase the sodium level in the blood, which could cause dehydration and electrolyte imbalance.

A hypertonic saline solution is not a source of glucose for the baby.

Normal ranges for blood glucose levels in newborns are between 47 to 85 mg/dL.Hypoglycemia is defined as blood glucose below 47 mg/dL.

Correct Answer is C

Explanation

Jitteriness and poor feeding are common signs of hypoglycemia in a newborn.

Hypoglycemia is when the level of sugar (glucose) in the blood is too low.

Glucose is the main source of fuel for the brain and the body.In a newborn baby, low blood sugar can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.

Choice A is wrong because hypertension and bradycardia are not typical symptoms of hypoglycemia in a newborn.

They may indicate other conditions such as heart problems or infection.

Choice B is wrong because diarrhea and vomiting are not specific symptoms of hypoglycemia in a newborn.

They may be caused by many other factors such as infection, food intolerance, or gastroesophageal reflux.

Choice D is wrong because hyperactivity and irritability are not usual symptoms of hypoglycemia in a newborn.

They may be signs of other conditions such as pain, hunger, or overstimulation.

Normal ranges for blood glucose levels in newborns vary depending on the age, gestational age, and feeding status of the baby.Most doctors consider blood glucose that is below 47 milligrams per deciliter (mg/dl) to be the definition of hypoglycemia in newborns.

However, some babies may need higher levels to prevent brain injury.

A doctor will monitor the blood glucose levels of a newborn at risk for hypoglycemia and treat accordingly.

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Naxlex Comprehensive Predictor Exams

A newborn is diagnosed with hypoglycemia. Which intervention should the nurse prioritize?

Correct Answer is B

Explanation

The nurse is educating a client about the signs and symptoms of hypoglycemia in a newborn. Which of the following should the nurse include?

Correct Answer is C

Explanation

A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution. Which of the following interventions should the nurse include in the plan?

A nurse is planning care for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse include in the plan?

A nurse is evaluating a client who received an immunization for tetanus one week ago. The client reports pain and swelling at the injection site, low-grade fever, and body aches. Which of the following responses should the nurse make?

A nurse is caring for a preterm infant who has intraventricular hemorrhage (IVH). Which of the following actions should the nurse take to prevent increased intracranial pressure (ICP)?

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform?

A nurse is preparing to administer an exchange transfusion to a newborn who has severe hyperbilirubinemia due to Rh incompatibility. Which of the following actions should the nurse take first?

A nurse is caring for a client who is at 42 weeks of gestation and is in labor. The client asked the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?

A nurse is evaluating the effectiveness of phototherapy for a post-term infant who has hyperbilirubinemia due to ABO incompatibility with the mother’s blood type O negative and infant’s blood type B positive. Which of the following findings indicates that phototherapy is effective?