A multiparous client with a history of previous cesarean birth is admitted for labor induction with oxytocin. Which of the following actions is most important before initiating therapy?
Administer an IV fluid bolus.
Insert a urinary catheter.
Perform a glucose monitoring.
Verify continuous electronic fetal monitoring is in place.
The Correct Answer is D
Choice A reason: Administering an IV fluid bolus may be helpful in preventing hypotension or maintaining hydration, but it is not the most critical action before oxytocin induction. Oxytocin can cause uterine tachysystole and fetal distress, so fluid bolus alone does not address the primary risk.
Choice B reason: Inserting a urinary catheter can help monitor urine output and bladder distension, but it is not essential before starting oxytocin. Catheterization is more relevant in surgical or anesthesia contexts rather than induction safety.
Choice C reason: Performing glucose monitoring is important in diabetic clients, but it is not universally required before oxytocin induction. Oxytocin does not directly alter glucose metabolism, so this is not the priority action.
Choice D reason: Continuous electronic fetal monitoring is the most important action because oxytocin increases uterine contractions, which can reduce placental perfusion and oxygen delivery to the fetus. A client with a prior cesarean is at higher risk for uterine rupture, so monitoring ensures early detection of fetal distress or abnormal contraction patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A fundus above the umbilicus and deviated to the right indicates bladder distention. Encouraging the client to void relieves bladder pressure, allowing the uterus to contract normally and return to midline.
Choice B reason: Fundal massage is indicated for uterine atony, not bladder distention. Massage will not correct displacement caused by a full bladder.
Choice C reason: Immediate notification of the provider is not necessary until nursing interventions fail. Voiding is the first-line intervention.
Choice D reason: Retained placental fragments cause uterine atony and abnormal bleeding, not fundal deviation. The clinical picture here is consistent with bladder distention.
Correct Answer is A
Explanation
Choice A reason: Two days postpartum, the uterus continues to involute and descends approximately 2 cm below the umbilicus. This is a normal finding in the process of uterine involution.
Choice B reason: By 1 week postpartum, the uterus is still palpable but has descended further into the pelvis. It does not become nonpalpable until about 2 weeks postpartum.
Choice C reason: The uterus does not remain an oval shape. After delivery, it gradually returns to its pre-pregnancy size and shape through involution.
Choice D reason: Immediately after delivery of the placenta, the uterus is about 2–3 cm above the umbilicus. This is not the expected finding 2 days postpartum.
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