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 D
Explanation
Choice A rationale
The weight of the newborn is not a factor in the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections caused by bacteria present in the mother’s birth canal, and this risk is not related to the newborn’s weight.
Choice B rationale
Whether the newborn was delivered via cesarean birth or vaginal birth does not affect the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections that can occur regardless of the method of delivery.
Choice C rationale
While it is important to monitor newborns for signs of infection, delaying the instillation of antibiotic ophthalmic ointment would not aid in identifying manifestations of infection. The ointment is a preventative measure and does not interfere with the observation of symptoms.
Choice D rationale
Correct answer. The instillation of antibiotic ophthalmic ointment can cause blurred vision in the newborn. Delaying the instillation of the ointment facilitates immediate bonding between the newborn and parent, as the newborn will be able to see more clearly.
Correct Answer is B
Explanation
Choice A rationale
Obtaining a specimen for a Kleihauer-Betke test is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
Choice B rationale
Misoprostol is a medication that can be used to treat uterine atony. It helps to contract the uterus and reduce bleeding.
Choice C rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication often used to mature the lungs of a fetus at risk of premature birth, not to treat uterine atony.
Choice D rationale
Avoiding sterile vaginal examinations is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
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