A nurse is caring for a client in the labor and delivery unit and is completing an assessment at 0900.
Which of the following actions should the nurse take at 0900? (Select all that apply)
Initiate an IV fluid bolus
Discontinue oxytocin infusion
Notify the provider
Reposition client to lateral position
Titrate the oxytocin infusion to 8 mu/min per order
Correct Answer : C,D,E
Choice A rationale:
Initiating an IV fluid bolus is not necessary at this time as the client’s vital signs are stable, and there is no evidence of dehydration or hypotension. The client’s blood pressure is within normal limits, and there are no signs of fluid imbalance.
Choice B rationale:
Discontinuing oxytocin infusion is not warranted as the current dosage of oxytocin is aiding in the progression of labor. The fetal heart rate is stable, and there are no signs of fetal distress or hyperstimulation of the uterus.
Choice C rationale:
Notifying the provider is important to keep them updated on the client’s progress and any changes in the labor process. This allows the provider to make informed decisions about further management and interventions if necessary.
Choice D rationale:
Repositioning the client to a lateral position can enhance uteroplacental perfusion and improve fetal oxygenation. It also helps in relieving maternal discomfort and promotes optimal fetal positioning for labor progress.
Choice E rationale:
Titrating the oxytocin infusion to 8 mu/min per order is appropriate as the current contraction pattern is not yet within the desired frequency and duration. Increasing the oxytocin dosage helps achieve effective labor contractions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Category 1 fetal heart rate tracings are considered normal and reassuring, showing a baseline rate of 110-160 bpm, moderate variability, and accelerations with no late or variable decelerations.
Choice B rationale
Category 2 fetal heart rate tracings are indeterminate and may show minimal or marked variability, but they do not have absent variability with bradycardia.
Choice C rationale
Category 3 fetal heart rate tracings are abnormal and require immediate intervention. They include absent variability with recurrent late decelerations, recurrent variable decelerations, bradycardia, or a sinusoidal pattern.
Choice D rationale
A reactive tracing shows accelerations of the fetal heart rate with fetal movement, indicating well-being. This scenario does not fit the description of a reactive tracing.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Initiating an IV fluid bolus is not necessary at this time as the client’s vital signs are stable, and there is no evidence of dehydration or hypotension. The client’s blood pressure is within normal limits, and there are no signs of fluid imbalance.
Choice B rationale:
Discontinuing oxytocin infusion is not warranted as the current dosage of oxytocin is aiding in the progression of labor. The fetal heart rate is stable, and there are no signs of fetal distress or hyperstimulation of the uterus.
Choice C rationale:
Notifying the provider is important to keep them updated on the client’s progress and any changes in the labor process. This allows the provider to make informed decisions about further management and interventions if necessary.
Choice D rationale:
Repositioning the client to a lateral position can enhance uteroplacental perfusion and improve fetal oxygenation. It also helps in relieving maternal discomfort and promotes optimal fetal positioning for labor progress.
Choice E rationale:
Titrating the oxytocin infusion to 8 mu/min per order is appropriate as the current contraction pattern is not yet within the desired frequency and duration. Increasing the oxytocin dosage helps achieve effective labor contractions
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