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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
Choice B rationale
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
Choice C rationale
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
Choice D rationale
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
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