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 A

Explanation

The nurse should first assess the fundus of the uterus. If the uterus is not firm (boggy), it may not be contracting well enough to compress the blood vessels and stop the bleeding. The nurse should massage the fundus until it is firm.

A. At the level of the umbilicus B. To the right of the umbilicus C. One fingerbreadth above the symphysis pubis D. 2 cm above the umbilicus E. 2 cm above the umbilicus

Correct Answer is A

Explanation

At the level of the umbilicus. After a vaginal delivery, the nurse should expect to find the uterine fundus at the level of the umbilicus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes.What should be the nurse’s first action?

Correct Answer is A

Explanation

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination.Which of the following explanations of the primary reason should the nurse provide?

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. What information should the nurse give to the client?

A nurse is caring for a client who is postpartum and is breastfeeding. The client states that she is concerned about dietary precautions since she has a family history of food allergies. The nurse offers which of the following responses?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who had a vaginal delivery 2 hours ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

What is the role of a nurse in assessing a pregnant woman’s diet?

A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period. What should be the priority nursing intervention at this time?

A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which postpartum complications?