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 C

Explanation

Choice A rationale
Inserting an indwelling urinary catheter is not the immediate next step. While it may be necessary in some cases, the priority is to address the client’s excessive bleeding, which is a sign of postpartum hemorrhage.
Choice B rationale
Administering oxytocin by continuous IV infusion is a common intervention for postpartum hemorrhage. However, it is not the immediate next step. The nurse should first attempt to massage the client’s fundus to promote contractions and control bleeding.
Choice C rationale
Massaging the client’s fundus is the correct next step. The client’s symptoms indicate postpartum hemorrhage, a serious condition that can lead to shock and other complications. Fundal massage often helps the uterus contract and can stop the bleeding.
Choice D rationale
Tilting the client onto her right side with her legs elevated to at least 30 degrees is not the immediate next step. This position can help improve venous return but does not directly address the cause of the client’s symptoms.

A. The infant needing more sleep can indicate a food allergy. B. Rice cereals can be a problem during lactation. C. Foods you eat do not affect breast milk. D. You might want to avoid eating peanuts.

Correct Answer is D

Explanation

Choice A rationale
While changes in an infant’s sleep patterns can be a sign of many issues, they are not a specific indicator of a food allergy.
Choice B rationale
Rice cereals are typically one of the first foods introduced to infants and are usually well- tolerated. They are not known to cause problems during lactation.
Choice C rationale

The foods a mother eats can affect breast milk, but they do not typically cause food allergies. Most babies can tolerate a variety of foods in a mother’s diet without any problems.
Choice D rationale
If there is a strong family history of peanut allergies, the mother might want to avoid eating peanuts while breastfeeding. However, current research suggests that early exposure to potential allergens may actually decrease the risk of developing allergies.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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?

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent defects in the fetus?

A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do if her newborn is persistently crying. Which of the following strategies should the nurse suggest? (Select all that apply.)

A nurse is caring for a patient who experienced a vaginal birth 3 hours ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which actions should the nurse take at this time?

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 receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?