A pregnant client in labor is having contractions about 4 minutes apart but rarely higher than 20 mm Hg in strength with resting tone ranging from 5 to 8 mm Hg. The client asks what can be done to make contractions more effective.
What is the nurse's best response to the client?
You may need oxytocin to strengthen contractions.
Relax, because contractions of this kind will strengthen by themselves.
Get some rest, because the contractions are hypertonic.
Try sitting up a little more erect to make the contractions more regular.
The Correct Answer is A
Choice A rationale
Contractions that are only 20 mm Hg in strength with a baseline resting tone of 5 to 8 mm Hg indicate hypotonic uterine dysfunction. This is characterized by insufficient uterine contraction power, not hypertonic resting tone. Oxytocin is an exogenous hormone that mimics the effects of the naturally released hormone, acting on uterine smooth muscle cells to increase the frequency, duration, and strength (intensity) of the contractions, which should ideally be 50 to 80 mm Hg during active labor.
Choice B rationale
Suggesting relaxation is inappropriate because these contraction patterns are ineffective and unlikely to spontaneously strengthen enough to cause adequate cervical change. Hypotonic contractions typically lead to a protracted labor pattern. The smooth muscle fibers of the uterus require sufficient stimulation to fully activate the contractile proteins actin and myosin. The low intensity and inadequate pressure of these contractions will not result in optimal cervical effacement and dilation.
Choice C rationale
These contractions are hypotonic, not hypertonic. Hypertonic contractions are characterized by high resting tone (above 15 mm Hg) and often painful, ineffective, erratic contractions. A period of rest is generally recommended for hypertonic contractions to reduce uterine irritability and oxygen consumption. However, for hypotonic dysfunction, augmentation (Choice A) is usually required to safely expedite the labor process and reduce risk of infection.
Choice D rationale
While upright positions like sitting or walking can use gravity to help the fetal head apply pressure to the cervix and stimulate endogenous oxytocin release, this response is less effective than recognizing the need for potential pharmacological augmentation. The contractions are described as rarely higher than 20 mm Hg, suggesting a significant need for intervention beyond simple position change to achieve the necessary 50 to 80 mm Hg intensity for progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing a rolled towel under the client's knees causes increased pressure on the popliteal space, potentially compressing the popliteal vein, which increases the risk of deep vein thrombosis (DVT) in the client. This is particularly concerning during labor due to physiologic hypercoagulability and potential for immobility. The priority action must focus on fetal and maternal well-being following rupture of membranes (ROM). This action is non-essential and potentially harmful.
Choice B rationale
While notifying the healthcare provider is crucial, it is not the immediate priority when there is a risk of a severe complication like umbilical cord prolapse following the spontaneous rupture of membranes (ROM). The nurse's immediate action must be to rule out or intervene for fetal distress or cord prolapse. The provider can be notified after the initial fetal status assessment is complete, especially the fetal heart rate (FHR).
Choice C rationale
Administering oxygen via a non-rebreather mask (NRB) is indicated for maternal or fetal hypoxemia or distress, or as part of resuscitation measures. In an initially stable client without signs of severe respiratory distress or non-reassuring fetal heart rate (FHR) patterns, oxygen administration is not the priority. The initial action must be a rapid assessment of fetal status, specifically ruling out cord prolapse after rupture of membranes (ROM).
Choice D rationale
Rupture of membranes (ROM) prior to the fetal head being engaged or firmly applied to the cervix creates a significant risk for umbilical cord prolapse, which is a fetal emergency causing acute fetal hypoxemia due to cord compression. The immediate priority is to assess the fetal heart rate (FHR) and perform a sterile vaginal exam (SVE) to palpate for the prolapsed cord and assess the presenting part. FHR assessment detects distress; SVE detects the prolapse.
Correct Answer is ["12"]
Explanation
Step 1 is to convert the oxytocin concentration from units to milliunits (mU):. 20 units× 1000 mU/unit = 20000 mU.
Step 2 is to determine the concentration in mU/mL:. 20000 mU÷ 1000 mL = 20 mU/mL.
Step 3 is to calculate the infusion rate in mL/min:. 4 mU/min÷ (20 mU/mL) = 0.2 mL/min.
Step 4 is to convert the infusion rate from mL/min to mL/hr:. 0.2 mL/min× 60 min/hr = 12 mL/hr. The final calculated answer is 12 mL/hr.
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