A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
Start oxytocin infusion immediately.
Begin oxytocin 4 hours after misoprostol is given.
Ambulate the client after administration of misoprostol.
Administer misoprostol every 2 hours.
The Correct Answer is B
Choice A rationale
Starting oxytocin infusion immediately may cause uterine hyperstimulation in clients who have already responded to misoprostol. Close monitoring and spacing out uterotonic agents help prevent adverse effects like uterine tachysystole and fetal distress.
Choice B rationale
Beginning oxytocin 4 hours after misoprostol ensures sufficient time for cervical ripening and reduces the risk of uterine hyperstimulation. This allows for safer labor induction and better outcomes for both mother and fetus.
Choice C rationale
Ambulating the client after misoprostol administration is generally safe but doesn't address the need for controlled uterotonic administration. Monitoring and timing of further uterotonics are crucial to avoid adverse effects and ensure safe induction.
Choice D rationale
Administering misoprostol every 2 hours is not recommended due to the risk of uterine hyperstimulation. It’s important to follow safe dosing intervals to reduce the risk of complications such as uterine tachysystole and fetal compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Caput succedaneum is a benign swelling of the soft tissues of the scalp that crosses suture lines and does not require drainage.
Choice B rationale
Cephalhematoma is a collection of blood between the skull and periosteum that does not cross suture lines; it may contribute to jaundice as it is reabsorbed by the body.
Choice C rationale
While cephalhematoma usually resolves without intervention, it is important to monitor for potential complications, including jaundice, due to the breakdown of red blood cells.
Choice D rationale
Caput succedaneum typically resolves on its own without intervention, as the fluid is gradually absorbed by the body over time.
Correct Answer is ["C","E","G","H"]
Explanation
Choice A rationale
Explaining procedures is important for patient understanding and consent, but it does not directly stabilize the client's condition during an eclamptic seizure.
Choice B rationale
Treating nausea can provide symptomatic relief but does not address the primary concerns of airway protection, seizure control, and hemodynamic stability in eclamptic patients.
Choice C rationale
Ensuring side rails are padded prevents injury during seizures by providing a protective barrier, reducing the risk of trauma from uncontrolled movements.
Choice D rationale
Assisting with breast pumping does not directly impact the stabilization of an eclamptic patient. The priority is managing seizures and ensuring patient safety.
Choice E rationale
Evaluating blood pressure frequently allows for early detection of hypertension or hypotension, guiding appropriate interventions to maintain hemodynamic stability and prevent complications.
Choice F rationale
Evaluating for headache is important for assessing potential complications of eclampsia, such as intracranial hypertension, but does not directly stabilize the patient during an acute seizure.
Choice G rationale
Assessing deep tendon reflexes helps monitor neurological status and the effectiveness of magnesium sulfate therapy, guiding further treatment decisions to prevent complications.
Choice H rationale
Minimizing visitors reduces environmental stimuli, which can help lower stress levels and prevent triggering additional seizures, contributing to the patient's stabilization.
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