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
Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.
Choice B rationale
Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.
Choice C rationale
Respirations are within normal range (17/min) and do not require immediate intervention.
Choice D rationale
Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Based on the provided information:
- The client had a vacuum-assisted vaginal delivery with a heavy lochia and small clots noted.
- A boggy fundus and the need for oxytocin infusion also indicate an increased risk for excessive bleeding.
Given these observations, the client is at the highest risk for developing Postpartum hemorrhage (Option A) due to Heavy lochia with small clots (Option C).
So, the completed sentence would be:
"The client is at highest risk for developing Postpartum hemorrhage due to Heavy lochia with small clots."
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