A nurse is caring for a patient in labor who is receiving oxytocin (Pitocin) by IV infusion to stimulate uterine contractions.
Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?
Fetal heart rate of 90 beats per minute
Increased urinary output
Three contractions occurring within a 10-minute period
Adequate resting tone of the uterus palpated between contractions
Adequate resting tone of the uterus palpated between contractions
The Correct Answer is A
Choice A rationale:
Fetal heart rate of 90 beats per minute is a sign of fetal bradycardia, which is a serious and potentially life-threatening condition. It indicates that the fetus is not getting enough oxygen, and it can lead to fetal distress, brain damage, or even death.
Oxytocin can cause uterine hyperstimulation, which can reduce blood flow to the placenta and cause fetal bradycardia. Therefore, if the nurse observes a fetal heart rate of 90 beats per minute, it is essential to discontinue the oxytocin infusion immediately and notify the healthcare provider.
Choice B rationale:
Increased urinary output is not a direct contraindication to oxytocin administration. In fact, oxytocin can sometimes cause a decrease in urinary output due to its antidiuretic effects.
While a significant increase in urinary output could be a sign of fluid overload, it would not necessarily indicate that the oxytocin infusion needs to be discontinued. The nurse would need to assess the patient's overall fluid status and other clinical indicators to make this determination.
Choice C rationale:
Three contractions occurring within a 10-minute period is considered a normal contraction pattern during labor. It is not a sign of uterine hyperstimulation or fetal distress.
In fact, the goal of oxytocin administration is to achieve regular contractions that are occurring every 2-3 minutes and lasting 40-60 seconds. Therefore, this finding would not indicate that the oxytocin infusion needs to be discontinued.
Choice D rationale:
Adequate resting tone of the uterus palpated between contractions is a normal finding during labor. It indicates that the uterus is contracting effectively and is not at risk for uterine atony (lack of muscle tone).
This finding would not be a reason to discontinue the oxytocin infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Diagnosing a fetus with a genetic disorder is outside the scope of practice for nurses. This task requires specialized training and expertise in genetics and diagnostic procedures, typically held by physicians such as geneticists, maternal-fetal medicine specialists, or genetic counselors.
Nurses play a crucial role in genetic counseling, but their responsibilities focus on:
Educating patients about genetic risks and testing options.
Obtaining informed consent for genetic testing.
Coordinating genetic testing appointments and procedures.
Providing emotional support and counseling to patients and families.
Facilitating communication between patients, families, and other healthcare providers.
Advocating for patients' rights and needs.
Choice B rationale:
Providing emotional support is a core component of nursing care, including genetic counseling. Nurses are trained to provide empathetic and compassionate support to patients and families who are facing the challenges of genetic conditions. This includes:
Active listening and validation of feelings.
Assisting with coping mechanisms and stress management.
Connecting patients with support groups and resources.
Promoting resilience and hope.
Choice C rationale:
Identifying at-risk families is a vital role for nurses in genetic counseling. By recognizing families with a history of genetic disorders or those who exhibit risk factors, nurses can initiate early intervention and preventive measures. This includes:
Taking a thorough family history.
Assessing risk factors and potential genetic concerns.
Educating families about their potential risks.
Referring families for genetic counseling and testing as appropriate.
Choice D rationale:
Collaboration with other healthcare providers and referral for specialized care are essential aspects of genetic counseling. Nurses often work within interdisciplinary teams to provide comprehensive care for patients with genetic concerns. This includes:
Communicating with geneticists, genetic counselors, and other specialists.
Coordinating referrals for genetic testing, counseling, and treatment.
Ensuring continuity of care across different healthcare settings.
Correct Answer is B
Explanation
Choice A rationale:
Performing a vaginal exam is not the priority intervention for a client experiencing hypotension after an epidural. While a vaginal exam may be necessary to assess cervical dilation and fetal station, it does not address the underlying cause of the client's hypotension.
Additionally, a vaginal exam could potentially worsen the client's hypotension by stimulating the vagus nerve, which can lead to decreased heart rate and blood pressure.
Therefore, it is not the most appropriate initial response in this situation.
Choice B rationale:
Turning the client onto her side is the most appropriate initial response to hypotension after an epidural. This position helps to increase venous return to the heart, which can improve cardiac output and blood pressure.
It also helps to prevent aortocaval compression, which can occur when the pregnant uterus compresses the inferior vena cava, reducing blood flow back to the heart.
By turning the client onto her side, the nurse can quickly and easily address the underlying cause of the hypotension and help to improve the client's hemodynamic status.
Choice C rationale:
Catheterizing the client may be necessary if the client is unable to void spontaneously, but it is not the priority intervention for hypotension after an epidural.
Urinary retention can occur after an epidural, but it is not typically the cause of hypotension in this setting.
Therefore, catheterization would not be the most appropriate initial response.
Choice D rationale:
Decreasing the IV fluid rate may be necessary if the client is experiencing fluid overload, but it is not the priority intervention for hypotension after an epidural.
In fact, decreasing the IV fluid rate could potentially worsen the hypotension by reducing the circulating blood volume.
Therefore, it is not the most appropriate initial response.
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