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A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin.

The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds.

The fetal heart rate is 160 beats/minute with late decelerations.

What is the priority nursing action?

A.

Increase the rate of oxytocin infusion

B.

Administer oxygen via face mask at 10 L/minute

C.

Turn the client to her left side

D.

Notify the health care provider

Answer and Explanation

The Correct Answer is D

The correct answer is d. Notify the health care provider.

Rationale for Choice A:

  • Increasing the rate of oxytocin infusion is contraindicated in this situation.
  • Oxytocin stimulates uterine contractions, and the client is already experiencing excessively frequent and prolonged contractions.
  • Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
  • It could also put the client at higher risk for uterine rupture, a serious complication associated with oxytocin use.

Rationale for Choice B:

  • While administering oxygen is a common intervention for fetal distress, it's not the priority action in this case.
  • Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency, which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
  • Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.

Rationale for Choice C:

  • Turning the client to her left side is a recommended position to improve placental blood flow.
  • However, in this situation, it's not the priority action given the presence of late decelerations and excessive uterine contractions.
  • It may be a helpful adjunct measure, but it won't address the primary cause of fetal distress.

Rationale for Choice D:

  • Notifying the health care provider is the most crucial action because:
    • The client has severe pre-eclampsia, a serious condition that requires close monitoring and management.
    • The frequent and prolonged contractions, along with late decelerations in the fetal heart rate, indicate potential fetal distress.
    • The health care provider needs to be aware of these changes to make timely decisions regarding interventions, such as:
      • Adjusting the oxytocin infusion
      • Expediting delivery if necessary
      • Implementing other measures to improve fetal well-being
      • Closely monitoring the mother's condition to prevent complications of pre-eclampsia


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Related Questions

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

Explanation

The correct answer is choices B, C, D, and E.These are all risk factors for pre-eclampsia according to various sources.

Choice A is wrong because age over 35 years is not a risk factor for pre-eclampsia by itself, although it may be associated with other conditions that increase the risk, such as chronic hypertension or diabetes.

Pre-eclampsia is a complication of pregnancy that involves high blood pressure, protein in the urine, and organ damage.It can affect both the mother and the fetus and can lead to serious complications such as eclampsia (seizures), placental abruption, and stillbirth.It is more common in first pregnancies, especially with a new partner, because of the immune response to the foreign fetal antigens.Obesity, diabetes mellitus, and multiple gestation are also risk factors because they increase the metabolic and vascular demands on the placenta and the mother.

Normal ranges for blood pressure and proteinuria in pregnancy are:

• Blood pressure: less than 140/90 mmHg

• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL on a random urine sample

Correct Answer is A

Explanation

Respiratory rate 10/min.This indicatesmuscle weaknessanddifficulty breathing, which are symptoms ofmagnesium toxicity.Magnesium sulfate is a medication that can cause magnesium overdose if given in excess or if the patient has impaired kidney function.

Choice B.Urine output 40 mL/hr is wrong because this is within the normal range for urine output, which is 30 to 50 mL/hr.Urine output may decrease in severe cases of magnesium toxicity due to urine retention.

Choice C. Patellar reflex 2+ is wrong because this is a normal finding for the knee-jerk reflex.A low or absent patellar reflex may indicate magnesium toxicity, as it reflectsmuscle weaknessandnerve dysfunction.

Choice D.Serum magnesium level 4.5 mEq/L is wrong because this is within the normal range for serum magnesium, which is 1.7 to 2.3 mEq/L.Serum magnesium levels above 2.6 mEq/L can indicate hypermagnesemia or magnesium overdose.

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