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 C
Explanation
Choice A rationale:
Incorrect. The Human Genome Project revealed that humans have approximately 20,000-25,000 genes, not 1,000. This finding significantly expanded our understanding of the complexity of the human genome.
Choice B rationale:
Incorrect. The concept of one gene producing three proteins is not a discovery from the Human Genome Project. While some genes can produce multiple protein isoforms through alternative splicing, this is not a universal feature of human genes.
Choice C rationale:
Correct. This is a major finding from the Human Genome Project. It highlights that despite our apparent differences, humans share a remarkably high degree of genetic similarity. This finding has implications for understanding human evolution, disease susceptibility, and pharmacogenomics.
Key points:
The vast majority of our DNA is shared among all humans.
The small percentage of genetic variation accounts for individual differences and diversity.
This finding challenges previous notions of race and ethnicity based on genetic differences.
It emphasizes the common origins and shared heritage of all humans.
Choice D rationale:
Incorrect. While single gene testing has become more common for certain genetic disorders, it is unlikely to become a standardized test for all patients in the future. This is due to the complexity of human genetics and the diverse factors that contribute to health and disease.
Correct Answer is B
Explanation
Choice A rationale:
A positive contraction stress test (CST) indicates a potential problem with the fetal heart's response to uterine contractions, not spontaneous accelerations.
It's not consistent with the findings in this scenario.
Choice C rationale:
A negative CST would show no late decelerations in response to contractions, but it's not relevant here because contractions weren't induced.
Choice D rationale:
A non-reactive NST lacks the required accelerations, which are present in this case.
Choice B rationale:
Definition of reactive NST: A reactive NST is a reassuring fetal heart test that demonstrates a healthy fetal heart rate response to fetal movement. It's characterized by two or more fetal heart rate accelerations of at least 15 beats per minute (bpm) lasting at least 15 seconds within a 20-minute period.
Significance of the findings: The presence of three accelerations measuring 15 bpm by 15 seconds within 20 minutes meets the criteria for a reactive NST. This suggests that the fetal nervous system is functioning well and responding appropriately to stimuli, indicating a healthy fetal heart rate pattern.
Nurse's reporting: The nurse should accurately report this finding to the provider as a "reactive nonstress test (NST)." This information is crucial for clinical decision-making regarding the ongoing management of the pregnancy.
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