A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations.
What should the nurse do next?

Notify the charge nurse about the patient’s condition.

Discontinue the oxytocin infusion.

Reduce the rate of the oxytocin infusion.

Adjust the position of the fetal monitor transducers.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While notifying the charge nurse about the patient’s condition is an important step, it is not the immediate action that should be taken in this situation. The priority is to address the tachysystolic or tetanic contractions and variable fetal heart decelerations, which are signs of potential fetal distress.

Choice B rationale

Discontinuing the oxytocin infusion is the correct action. Oxytocin is a hormone that stimulates uterine contractions during labor. If a patient begins to experience tachysystolic or tetanic contractions, which are excessively frequent or prolonged contractions, it could lead to fetal distress. Discontinuing the oxytocin can help reduce the frequency and intensity of the contractions.

Choice C rationale

Reducing the rate of the oxytocin infusion may not be sufficient in this situation. Tachysystolic or tetanic contractions with variable fetal heart decelerations are serious signs that require immediate action. Simply reducing the rate of the infusion may not alleviate these symptoms quickly enough.

Choice D rationale

Adjusting the position of the fetal monitor transducers would not address the issue of tachysystolic or tetanic contractions. While it is important to ensure accurate monitoring of the fetus, the priority in this situation is to address the potentially harmful contractions.

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Correct Answer is A

Explanation

Choice A rationale

In the context of a fetus weighing an estimated 8 pounds at 36-weeks gestation in a client with gestational diabetes, an amniocentesis would most likely be performed to assess the maturity of the fetal lungs. This is because babies of mothers with gestational diabetes are at risk for

respiratory distress syndrome if delivered early, and the baby’s size may indicate that early delivery could be beneficial.

Choice B rationale

While amniocentesis can be used to detect neural tube defects, these are usually diagnosed earlier in pregnancy. Furthermore, there is no specific link between gestational diabetes, fetal weight, and neural tube defects that would make this the primary reason for performing an amniocentesis in this scenario.

Choice C rationale

Amniocentesis can be used to detect chromosomal abnormalities. However, these are typically screened for earlier in pregnancy and would not be directly related to the mother’s gestational diabetes or the estimated fetal weight.

Choice D rationale

The gender of the fetus can be determined through amniocentesis, but it can also be determined more simply through ultrasound. Therefore, it is unlikely that an amniocentesis would be performed for this purpose, especially considering the mother’s gestational diabetes and the baby’s size.

A. It stimulates the immune system. B. It aids an immature liver. C. It prevents hemorrhagic disorders. D. It compensates for insufficient dietary intake.

Correct Answer is C

Explanation

Choice A rationale

While it’s true that phytonadione, also known as vitamin K, plays a role in the immune system, this is not the primary reason it is given to newborns. Therefore, this statement does not show an understanding of why the medication is being given.

Choice B rationale

Phytonadione does not aid an immature liver. It is necessary for the synthesis of certain proteins required for blood clotting. However, it does not directly aid the liver’s function.

Choice C rationale

This is the correct statement. Phytonadione is given to newborns to prevent hemorrhagic disorders, specifically vitamin K deficiency bleeding (VKDB). Newborns are at risk for VKDB because their gut does not yet have the bacteria necessary to produce vitamin K5.

Choice D rationale

While it’s true that vitamin K is obtained from dietary intake, newborns do not receive phytonadione to compensate for insufficient dietary intake. They receive it to prevent VKDB, a bleeding disorder caused by vitamin K deficiency.

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A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations.What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with gestational diabetes is scheduled for an amniocentesis due to the fetus weighing an estimated 8 pounds (3629 grams) at 36-weeks gestation.What information is being sought through this amniocentesis?

Correct Answer is A

Explanation

The nurse is about to administer phytonadione to a newborn.Which statement by the parents shows they understand why this medication is being given?

Correct Answer is C

Explanation

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A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations.
What should the nurse do next?