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, and are strong to palpation. The baseline fetal heart rate is 150/minute, with uniform decelerations beginning at 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,
Discontinue the infusion of the IV oxytocin.
Decrease the rate of infusion of the maintenance IV selution.
Slow the client's rate of breathing.
The Correct Answer is B
A. Incorrect. Increasing the rate of infusion of the IV oxytocin would worsen the uterine hyperstimulation and fetal distress that are indicated by the frequent, long, and strong contractions and uniform decelerations.
B. Correct. Discontinuing the infusion of the IV oxytocin would stop the uterine hyperstimulation and allow the fetus to recover from hypoxia.
C. Incorrect. Decreasing the rate of infusion of the maintenance IV solution would not affect the uterine hyperstimulation or fetal distress, as they are caused by the oxytocin, not by the fluid volume.
D. Incorrect. Slowing the client's rate of breathing would not help with the uterine hyperstimulation or fetal distress, as they are not related to maternal hyperventilation or respiratory alkalosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Engagement of the presenting part occurs when the baby's head descends into the pelvis. While it is a sign of labor progression, it can also happen weeks before labor begins.
Choice B: Progressive changes in the effacement (thinning) and dilation (opening) of the cervix are the most reliable signs of true labor. As the cervix changes, it indicates that labor is actively occurring.
Choice C: Rupture of the membranes (water breaking) is another sign of labor, but it can happen before or during labor. It may not be the most reliable sign by itself.
Choice D: Regular and frequent contractions are essential for labor to progress, but an irregular pattern of contractions may still be associated with false labor or early labor.
Correct Answer is A
Explanation
A: Quickening, which refers to the sensation of the baby moving in the womb, is considered a presumptive sign of pregnancy. It is called "presumptive" because it is subjective and can be attributed to other causes, such as gas or gastrointestinal movements.
B: Positive signs of pregnancy are those that are attributed only to the presence of a fetus, such as fetal heartbeat or visualization on ultrasound. Feeling the baby move (quickening) is not specific enough to confirm pregnancy on its own.
C: Probable signs of pregnancy are more objective and can be detected by a healthcare provider, such as a positive pregnancy test or ballottement (rebounding of the fetus against the examiner's fingers). Feeling the baby move is not a probable sign as it is subjective and can be attributed to other factors.
D: "Potential sign of pregnancy" is not a recognized classification in pregnancy signs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.