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 C
Explanation
Choice A rationale
Vaginal candidiasis is not a contraindication for the use of a suppository. Candidiasis is a fungal infection that can cause itching and discomfort in the vaginal area. While it may require treatment, it does not prevent the use of a suppository for constipation.
Choice B rationale
Afterpains are not a contraindication for the use of a suppository. Afterpains are cramping pains that some women experience after childbirth as the uterus contracts back to its pre- pregnancy size. While they can be uncomfortable, they do not prevent the use of a suppository for constipation.
Choice C rationale
A third-degree perineal laceration is a contraindication for the use of a suppository. A third- degree laceration extends through the vaginal wall, perineal skin, and perineal muscles to the anal sphincter. Inserting a suppository could potentially cause further damage or introduce bacteria into the healing wound.
Choice D rationale
Abdominal distention is not a contraindication for the use of a suppository. While abdominal distention can be uncomfortable, it does not prevent the use of a suppository for constipation.
Correct Answer is D
Explanation
Choice A rationale
While surgical closure is a common treatment for myelomeningocele, it is not typically performed immediately after birth.
Choice B rationale
Cleansing the site with povidone-iodine is not typically the first step in caring for a newborn with a myelomeningocele.
Choice C rationale
Monitoring the rectal temperature every 4 hours is not specifically related to the care of a newborn with a myelomeningocele.
Choice D rationale
This is the correct answer. Administering broad-spectrum antibiotics can help prevent infection in a newborn with a myelomeningocele.
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