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:
Trisomy 21, also known as Down syndrome, is a genetic condition caused by the presence of an extra copy of chromosome 21.
The nuchal translucency test (NT) is a non-invasive ultrasound screening test that measures the thickness of the fluid-filled space at the back of a developing baby's neck.
Evidence suggests that fetuses with Down syndrome tend to have increased fluid accumulation in this area, resulting in a larger-than-average nuchal translucency measurement.
Therefore, an increased NT measurement can be a marker for an increased risk of Down syndrome.
It's important to emphasize that the NT test is a screening tool, not a diagnostic test.
This means it can only indicate an increased risk of Down syndrome; it cannot definitively diagnose the condition.
To confirm a diagnosis, further testing, such as chorionic villus sampling (CVS) or amniocentesis, is required.
Choice B rationale:
Neural tube defects (NTDs) are birth defects that affect the brain, spine, or spinal cord.
The most common NTDs are spina bifida and anencephaly.
The NT test is not a diagnostic test for NTDs, although it might detect some cases of open spina bifida.
However, it's not specifically designed for this purpose, and other tests, such as alpha-fetoprotein (AFP) screening or detailed ultrasound, are more reliable for diagnosing NTDs.
Choice C rationale:
The NT test is typically performed in the first trimester of pregnancy, between 11 and 14 weeks gestation.
It's not available in the second trimester because the nuchal translucency measurement becomes less reliable after this point in pregnancy.
Choice D rationale:
A nuchal translucency measurement of 3mm or less is generally considered normal.
Measurements greater than 3mm are associated with an increased risk of Down syndrome and other chromosomal abnormalities.
The higher the measurement, the greater the risk.
Correct Answer is C
Explanation
Choice A rationale:
It is true that a laboring client may not be able to eat, but this is not the primary reason for starting an IV. The client can receive fluids and electrolytes through the IV to maintain hydration and energy levels.
However, this response does not directly address the client's question about why the IV is necessary for the epidural.
It's important to provide a clear and accurate explanation to help the client understand the purpose of the intervention.
Choice B rationale:
This response is dismissive of the client's concerns and does not provide any information about why the IV is necessary.
It's important to acknowledge the client's concerns and provide them with the information they need to make informed decisions about their care.
Choice C rationale:
This is the correct response. The IV is necessary to administer medication for relaxation before the epidural is placed.
The epidural is a regional anesthetic that blocks pain signals from the lower body.
The medication for relaxation helps to reduce anxiety and discomfort, which can make it easier to place the epidural.
It also helps to prevent the client from moving during the procedure, which could lead to complications.
Choice D rationale:
This response is not accurate. An IV bolus is not typically given to minimize the side effects of the epidural.
Side effects of the epidural, such as hypotension and nausea, are usually managed with other medications.
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