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 B
Explanation
Choice A rationale
Oatmeal is a good source of dietary fiber, but it does not have the highest fiber content per cup compared to the other options. A cup of cooked oatmeal contains about 4 grams of fiber.
Choice B rationale
Lentils are an excellent source of dietary fiber. One cup of cooked lentils contains approximately 15.6 grams of fiber, which is significantly higher than the other options. This makes lentils a great choice for someone looking to increase their fiber intake, especially for those following a vegan diet.
Choice C rationale
Cabbage does contain fiber, but not as much as lentils or oatmeal. One cup of raw cabbage contains about 2.2 grams of fiber. While it’s a healthy vegetable to include in a diet, it’s not the best choice for someone specifically looking to increase their fiber intake.
Choice D rationale
Asparagus is another healthy vegetable that contains fiber, but not as much as the other options. One cup of cooked asparagus contains about 3.7 grams of fiber. While it’s a good choice for a balanced diet, there are better options for increasing fiber intake.
Correct Answer is D
Explanation
Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.
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