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 ["C","D","E"]

Explanation

Choice A rationale

Return of lochia rubra, or bright red bleeding, is not a sign of postpartum depression. It is a normal part of the postpartum period and can last for several weeks after childbirth.

Choice B rationale

Engorged, painful breasts can be a sign of breastfeeding complications, but they are not a sign of postpartum depression. They are a common experience for many women as their milk comes in after childbirth.

Choice C rationale

Difficulty falling asleep, even when the baby is sleeping, can be a sign of postpartum depression. Sleep disturbances are common among women with postpartum depression.

Choice D rationale

Decreased appetite can be a sign of postpartum depression. Changes in eating habits, such as eating too little or too much, are common symptoms of depression.

Choice E rationale

Feelings of sadness that last for more than two weeks after childbirth can be a sign of postpartum depression. While many women experience “baby blues” in the first few weeks after childbirth, prolonged feelings of sadness can indicate a more serious issue.

A. Episodes of headache and irritability. B. Persistent daytime fatigue. C. Nausea and vomiting. D. Rapid increase in abdominal girth.

Correct Answer is D

Explanation

Choice A rationale

While episodes of headache and irritability can occur as side effects of metformin and menotropins, they are not typically severe enough to warrant immediate reporting.

Choice B rationale

Persistent daytime fatigue can be a side effect of these medications, but it is also a common symptom in pregnancy and is not typically a cause for immediate concern.

Choice C rationale

Nausea and vomiting can occur as side effects of these medications. However, they are common side effects and are not typically a cause for immediate concern unless they are severe or persistent.

Choice D rationale

A rapid increase in abdominal girth can be a sign of ovarian hyperstimulation syndrome, a rare but potentially serious side effect of fertility treatments. This condition can cause rapid weight gain, abdominal pain, and bloating, and should be reported immediately.

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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

Which signs of postpartum depression require additional attention from the nurse? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A client who is anovulatory and has hyperprolactinemia is undergoing infertility treatment with metformin, menotropins, and human chorionic gonadotropin.What side effect should the nurse instruct the client to report immediately?

Correct Answer is D

Explanation

A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding.What advice should the nurse give the client?

Which type of anesthesia, when used with a laboring client, results in a loss of sensation confined to the vagina and perineum?

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?

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?

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

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?