A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

Stopping oxygen per cannula after uterine hyperstimulation and subsequent contraction reduction is not appropriate. Oxygen should be continued to ensure fetal oxygenation, particularly after a period of stress caused by frequent contractions. Discontinuing oxygen too soon may compromise fetal well-being.

Choice B rationale

Checking for clonus in both feet is unrelated to the management of uterine contractions post-oxytocin administration. Clonus assessment is used in evaluating neuromuscular function, often in conditions such as preeclampsia, but not for monitoring uterine activity or response to oxytocin.

Choice C rationale

Notifying the nursery about the client's response is important for continuity of care but does not address the immediate need to manage the uterine contractions. The primary focus should be on stabilizing uterine activity before updating other departments.

Choice D rationale

Restarting the oxytocin infusion rate per protocol is the correct intervention after ensuring that the contractions have reduced to a safe frequency and duration. This approach helps to maintain labor progress while minimizing the risk of hyperstimulation and fetal distress. The nurse should follow the hospital's guidelines for oxytocin titration.

Choice A rationale

Assessing the fetal heart rate and client's contraction pattern is the highest priority when a large amount of bright red vaginal bleeding occurs. It is crucial to evaluate fetal well-being and the progression of labor to determine any immediate interventions needed to ensure the safety of both the mother and fetus.

Choice B rationale

Confirming Rh and Coombs status for Rho(D) immunoglobulin administration is important for Rh-negative mothers, but it is not the immediate priority in the presence of significant vaginal bleeding. Ensuring fetal and maternal stability takes precedence over Rh status confirmation.

Choice C rationale

Determining fetal position by performing Leopold maneuvers is not the highest priority when there is significant vaginal bleeding. While fetal position is relevant, immediate assessment of fetal heart rate and maternal contraction pattern is more critical for evaluating the urgency of the situation.

Choice D rationale

Performing a sterile vaginal examination to determine dilation is contraindicated in the presence of vaginal bleeding, as it can exacerbate the situation and lead to further complications. Immediate assessment of fetal well-being and maternal condition is more crucial before considering any internal examination. .