A nurse on the labor and delivery unit is caring for a patient undergoing labor induction with oxytocin administered through a secondary IV line.

Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation.

The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over.

What action should the nurse take?

Slow the client’s rate of breathing.

Increase the rate of infusion of the IV oxytocin.

Discontinue the infusion of the IV oxytocin.

Decrease the rate of infusion of the maintenance IV solution.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Slowing the client’s rate of breathing would not directly address the issue of strong, frequent contractions and uniform decelerations of the fetal heart rate. These symptoms suggest uterine hyperstimulation, which can compromise fetal oxygenation.
Choice B rationale
Increasing the rate of infusion of the IV oxytocin would likely exacerbate the problem, as oxytocin can cause uterine hyperstimulation, leading to reduced fetal oxygen supply.
Choice C rationale
Discontinuing the infusion of the IV oxytocin is the appropriate action. The pattern of contractions and fetal heart rate decelerations suggest uterine hyperstimulation, which can be caused by excessive oxytocin. Stopping the oxytocin infusion can help to normalize the contraction pattern and improve fetal oxygenation.
Choice D rationale
Decreasing the rate of infusion of the maintenance IV solution would not directly address the issue of uterine hyperstimulation and fetal heart rate decelerations.

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Correct Answer is B

Explanation

Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice B rationale
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood. In the case of a term macrosomic newborn whose mother has poorly controlled type 2 diabetes, the baby’s pancreas may produce extra insulin in response to the mother’s high blood glucose levels. This excess insulin can delay surfactant production, which is needed for lung maturation, leading to respiratory distress syndrome.
Choice C rationale
Brachial plexus injury is a type of birth injury that can occur due to the baby’s large size and difficulty being born. However, it is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice D rationale

Increased blood viscosity can occur in newborns of mothers with poorly controlled diabetes due to polycythemia (an abnormally high number of red blood cells). However, this is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn.

A. I should start giving solid foods to my baby when they are 3 months old. B. I should wait until my baby is 4 months old to begin fluoride supplements. C. I should wait to give fruit juice until my baby is 6 months old. D. I should introduce cow’s milk when my baby is 9 months old.

Correct Answer is C

Explanation

Choice A rationale
Introducing solid foods to a baby at 3 months old is not recommended. The American Academy of Pediatrics suggests exclusive breastfeeding for the first 6 months of life.
Choice B rationale
The American Dental Association recommends that a child is at least 6 months old before they start using fluoride supplements, and only if the child is at high risk for tooth decay and the primary drinking water source is deficient in fluoride.
Choice C rationale
Waiting to give fruit juice until a baby is 6 months old is a correct practice. The American Academy of Pediatrics recommends that fruit juice should not be introduced into the diet of infants before 6 months of age.
Choice D rationale
Introducing cow’s milk when a baby is 9 months old is not recommended. The American Academy of Pediatrics advises against introducing cow’s milk until a child is 12 months old.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes?

Correct Answer is B

Explanation

A nurse is providing nutritional guidance to a parent of a newborn. Which statement by the parent indicates an understanding of the teaching?

Correct Answer is C

Explanation

What is the estimated date of birth (EDB) for a client who is pregnant and whose last menstrual period began on July 27? (State the date in MMDD. For example, July 27 is 0727)

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client’s amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor, which of the following assessment findings should the nurse report to the provider first?

A nurse is assessing a newborn who has Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.)

The nurse is conducting a newborn assessment and identifies a collection of blood beneath the newborn’s scalp that does not cross the suture lines. How should the nurse document this finding?

What is important for a woman to understand before undergoing a scheduled tubal ligation?

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client’s oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?