A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out.
Which intervention would the nurse expect to include in the plan of care for this client?
Encouraging the woman to assume a hands-and-knees position.
Providing a comfortable environment with dim lighting.
Administering oxytocin.
Preparing the woman for an amniotomy.
The Correct Answer is C
Choice A rationale
Encouraging a hands-and-knees position may help rotate a malpositioned fetus or relieve back pain, but it does not directly address hypotonic uterine dysfunction, which is characterized by weak, ineffective contractions. While it can improve maternal comfort and potentially aid in fetal descent if malpositioning is a contributing factor to slow labor progress, it will not augment the strength or frequency of contractions necessary for cervical dilation.
Choice B rationale
Providing a comfortable environment with dim lighting can promote relaxation and potentially enhance the progress of labor in cases of hypertonic uterine dysfunction (uncoordinated, painful contractions). However, in hypotonic dysfunction, the issue is a lack of adequate uterine muscle activity. While comfort measures are always important, they do not directly stimulate stronger contractions.
Choice C rationale
Administering oxytocin is the primary medical intervention for hypotonic uterine dysfunction. Oxytocin is a synthetic hormone that stimulates uterine smooth muscle to contract more frequently and with greater intensity. This augmentation of uterine activity aims to establish an effective labor pattern, leading to cervical dilation and fetal descent when fetopelvic disproportion has been ruled out.
Choice D rationale
Preparing for an amniotomy (artificial rupture of membranes) might be considered to augment labor if the membranes are intact. However, the question states the membranes have already ruptured. Amniotomy can sometimes stimulate contractions by releasing prostaglandins, but it is not the first-line intervention for established hypotonic dysfunction after membrane rupture, and oxytocin is generally more effective in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["7"]
Explanation
Step 1: Heart rate of 110/min scores 2 points (normal heart rate >100).
Step 2: Slow weak cry scores 1 point (good strong cry scores 2, no cry scores 0).
Step 3: Some flexion of extremities scores 1 point (active movement scores 2, limp scores 0).
Step 4: Grimace in response to suctioning scores 1 point (coughing or sneezing scores 2, no response scores 0).
Step 5: Body pink, blue extremities scores 1 point (completely pink scores 2, completely blue or pale scores 0).
Step 6: Total Apgar score is the sum of the scores from each category: 2 + 1 + 1 + 1 + 2 = 7. Final calculated answer: 7.
Correct Answer is []
Explanation
Rationale for Correct Condition
Subinvolution refers to delayed uterine involution, often due to retained placental fragments or infection. The boggy uterus, excessive lochia, and passage of clots are hallmark signs. The history of postpartum hemorrhage increases risk, and fundal tenderness suggests uterine atony rather than infection or hematoma formation.
Rationale for Correct Actions
Oxytocin enhances uterine contractions to reduce bleeding and facilitate involution by increasing myometrial tone. Methylergonovine is a potent uterotonic that further supports contraction, decreasing hemorrhage risk, but must be used cautiously in hypertensive patients.
Rationale for Correct Parameters
Saturated perineal pads track blood loss severity, guiding interventions for ongoing hemorrhage. Excessive bleeding may require further medical management. Hemoglobin and hematocrit assess for anemia due to blood loss, guiding transfusion decisions if needed.
Rationale for Incorrect Conditions
Postpartum preeclampsia presents with hypertension and proteinuria, not uterine atony. Perineal hematoma manifests as localized swelling with severe perineal pain, which is absent here. Thrombophlebitis involves unilateral extremity swelling and pain, not fundal tenderness or abnormal lochia.
Rationale for Incorrect Actions
Ice packs to the perineum manage hematomas, not uterine atony. Anticoagulants are used for thromboembolic prevention, not postpartum bleeding. Quiet environment is relevant for preeclampsia, not uterine subinvolution.
Rationale for Incorrect Parameters
Seizures are relevant to preeclampsia, not uterine subinvolution. Calf circumference is monitored for thrombophlebitis, which is absent here. Rectal pain is not an expected indicator of uterine involution status.
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