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 A
Explanation
Choice A rationale
A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.
Choice B rationale
Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.
Choice C rationale
Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.
Choice D rationale
Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.
Correct Answer is C
Explanation
Choice A rationale
Collecting a urine sample for dipstick analysis can identify urinary tract infections (UTIs) or other abnormalities. Dipstick tests detect leukocytes, nitrites, protein, and glucose, providing rapid results for initial screening of urinary issues.
Choice B rationale
Asking the client if she had sexual intercourse yesterday may help identify potential causes of urinary frequency, such as post-coital irritation. However, it does not directly address the irregular uterine contractions or possible infections.
Choice C rationale
Obtaining a midstream urine specimen for culture is crucial for diagnosing UTIs, which can cause urinary frequency and uterine irritability. Culturing urine identifies specific pathogens, guiding targeted antibiotic therapy to treat the infection.
Choice D rationale
Determining if she has a change in vaginal discharge can indicate infections or other conditions affecting the reproductive tract. However, it does not directly address the urinary frequency or irregular uterine contractions, making it less immediate.
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