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
Obtaining a blood sample for complete blood count is crucial but secondary. The client’s low blood pressure and high heart rate indicate possible hypovolemia requiring immediate intervention to restore blood pressure and perfusion.
Choice B rationale
Infusing normal saline helps restore blood volume. However, it won't address supine hypotension syndrome, caused by uterine compression of the inferior vena cava, which necessitates repositioning the client first to improve hemodynamic stability.
Choice C rationale
Palpating the abdomen for contractions is important in assessing labor progress. Yet, it doesn't address the immediate hemodynamic instability caused by supine hypotension, which needs immediate correction to avoid fetal compromise.
Choice D rationale
Tilting the backboard laterally displaces the uterus off the inferior vena cava, alleviating supine hypotension syndrome. This improves maternal blood pressure and fetal perfusion, addressing the immediate hemodynamic instability effectively.
Correct Answer is ["36"]
Explanation
Step 1 is: Convert 10 units to milliunits: 10 units × 1,000 milliunits/unit = 10,000 milliunits.
Step 2 is: Calculate the infusion rate: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min.
Step 3 is: Convert the infusion rate to mL/hour: 0.6 mL/min × 60 min/hour = 36 mL/hour. Final calculated answer: 36 mL/hour.
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