A nurse is caring for a client who is receiving 1 milliunit/min of oxytocin for the induction of labor.

The provider prescription reads to increase the rate by 1 milliunit per/min every 30 min until the client demonstrates an expected labor pattern.

The cervical Bishop score is 2. The monitor indicates contractions every 1 min.

Which of the following findings indicates the nurse should titrate the infusion rate to 2 milliunits/min after the first 30 min?

The client's contractions palpate as mild.

The client experiences spontaneous rupture of membranes.

The client's pain level decreases.

The client's blood pressure stabilizes.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Palpating contractions as mild indicates that the current oxytocin dose is likely insufficient to achieve an expected labor pattern. Oxytocin aims to induce moderate-to-strong uterine contractions, typically occurring every 2-3 minutes, lasting 40-90 seconds. Mild contractions suggest suboptimal uterine activity, justifying an increase in the infusion rate to stimulate more effective contractions.

Choice B rationale

Spontaneous rupture of membranes is a natural progression of labor and does not directly indicate the need to titrate oxytocin based on uterine contraction effectiveness. While rupture of membranes can accelerate labor, the oxytocin titration decisions are primarily based on the intensity and frequency of uterine contractions, not the status of the amniotic sac.

Choice C rationale

A decrease in the client's pain level is not an indicator for titrating oxytocin for labor induction. Pain is subjective and influenced by various factors, including analgesia. Oxytocin titration is guided by objective measures of uterine activity and cervical change, aiming for an adequate labor pattern rather than pain management.

Choice D rationale

Stabilization of the client's blood pressure, while desirable, is not a direct parameter for titrating oxytocin to achieve an expected labor pattern. Oxytocin's primary effect is on uterine contractility, and titration decisions are based on the frequency, duration, and intensity of contractions, and cervical dilation, not systemic blood pressure changes.

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Free Nursing Study Resources

Correct Answer is A,B,C,D

Explanation

Observe the newborn's respirations. Auscultate the newborn's heart rate. Auscultate newborn's abdomen. Test the newborn's reflexes.

A. Ensure calcium gluconate is readily available. B. Obtain the client’s heart rate. C. Evaluate the client’s platelet count. D. Determine if the client has aspirin sensitivity. E. Review the client’s history for documentation of heart disease.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.

Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.

Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.

Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.

Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a physical examination of a term newborn upon admission to the nursery. In which order should the nurse perform the following assessments?

Correct Answer is A,B,C,D

Explanation

A nurse is admitting a female client, age 34, who is at 38 weeks of gestation to the labor and delivery unit for induction of labor. Which of the following actions should the nurse take prior to implementing the provider’s prescriptions?

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is providing instruction to a client about diagnostic tests during their first prenatal visit at 12 weeks of gestation. Which of the following diagnostic tests should the nurse include in the teaching?

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A nurse is assessing four clients in a prenatal clinic. Which of the following clients should the nurse recommend that the provider see first?

A nurse is performing a nonstress test for a client who is at 38 weeks of gestation. The fetal monitor tracing reveals a series of late decelerations. Which of the following interventions should the nurse implement first?

A nurse is reviewing a client's rubella titer of 1:8 at her second prenatal visit. Which of the following statements by the nurse is appropriate?

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