A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line.Uterine contractions occur every 2 minutes, last 90 seconds each, and are strong to palpation.
The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction, nadir after the peak of the contraction, and a return to baseline after the contraction is over.
Which of the following actions should the nurse take?
Increase the rate of infusion of the IV oxytocin.
Decrease the rate of infusion of the maintenance IV solution.
Discontinue the infusion of the IV oxytocin.
Slow the client's rate of breathing.
The Correct Answer is C
Choice A rationale
Increasing the rate of infusion of IV oxytocin in the presence of abnormal fetal heart rate decelerations is contraindicated. It may exacerbate uterine hyperstimulation, further compromising fetal oxygenation.
Choice B rationale
Decreasing the rate of infusion of the maintenance IV solution will not address the issue of uterine hyperstimulation or abnormal fetal heart rate decelerations. The focus should be on managing oxytocin administration.
Choice C rationale
Discontinuing the infusion of IV oxytocin is appropriate due to uterine tachysystole and associated fetal heart rate decelerations. This helps reduce uterine contractions and allows for fetal recovery, improving oxygenation.
Choice D rationale
Slowing the client's rate of breathing is not related to managing uterine contractions or fetal heart rate decelerations. The intervention should directly address the cause of the decelerations, which is oxytocin-induced hyperstimulation. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Betamethasone is a corticosteroid that accelerates fetal lung maturity by increasing the production of surfactant, which reduces respiratory distress syndrome in preterm infants.
Choice B rationale
While betamethasone can cause transient increases in fetal heart rate, its primary purpose is not to increase fetal heart rate. Its role is in enhancing lung maturity.
Choice C rationale
Betamethasone does not directly increase amniotic fluid levels. Its main function is in the maturation of fetal lungs.
Choice D rationale
Betamethasone is not used to stop preterm labor contractions. It is used to accelerate fetal lung development in preterm labor cases.
Correct Answer is D
Explanation
Choice A rationale
Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.
Choice B rationale
Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.
Choice C rationale
Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.
Choice D rationale
A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .
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