A nurse is caring for a patient who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR.
After discontinuing the infusion, what action should the nurse take?
Initiate an amnioinfusion.
Place the patient in a supine position.
Instruct the patient to bear down and push with contractions.
Administer oxygen at 10 L/min via non-rebreather face mask.
The Correct Answer is D
Choice A rationale
Initiating an amnioinfusion is not the first action to take after discontinuing oxytocin infusion due to persistent late decelerations in the FHR. Amnioinfusion is a procedure where a saline solution is infused into the uterus to increase the volume of amniotic fluid. It is typically used to treat variable decelerations in the FHR, not late decelerations.
Choice B rationale
Placing the patient in a supine position is not recommended as it can decrease blood flow to the uterus and fetus, potentially worsening the late decelerations.
Choice C rationale
Instructing the patient to bear down and push with contractions is not appropriate in this situation. Persistent late decelerations in the FHR are a sign of fetal distress, and further contractions could exacerbate this.
Choice D rationale
Administering oxygen at 10 L/min via a non-rebreather face mask is the correct action. This increases the amount of oxygen available to the mother and fetus, potentially improving the FHR pattern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Breast tenderness is a common side effect of clomiphene citrate. This medication stimulates the release of hormones needed for ovulation, which can also cause changes in breast tissue leading to tenderness.
Choice B rationale
Urinary frequency is not a known side effect of clomiphene citrate. However, urinary frequency can be a symptom of pregnancy, which is the intended outcome of using this medication.
Choice C rationale
Chills are not a known side effect of clomiphene citrate. If a patient experiences chills while taking this medication, it may be due to other causes and should be evaluated by a healthcare provider.
Choice D rationale
Tinnitus, or ringing in the ears, is not a known side effect of clomiphene citrate. If a patient experiences tinnitus while taking this medication, it may be due to other causes and should be evaluated by a healthcare provider.
Correct Answer is C
Explanation
Choice A rationale
Massaging the client’s fundus is not indicated in this situation. Fundal massage is typically done after childbirth to help the uterus contract and prevent excessive bleeding.
Choice B rationale
Applying oxygen can help increase the client’s oxygen saturation levels, but it does not directly address the cause of the hypotension.
Choice C rationale
Turning the client to a side-lying position, specifically the left lateral position, can help improve blood flow to the heart, increasing cardiac output and blood pressure.
Choice D rationale
Assisting the client to empty their bladder is important in postpartum care, but it is not the immediate action to take when a client is hypotensive following the administration of epidural anesthesia.
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