A primipara client at 42-weeks gestation is admitted for induction.Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75 second duration.
The nurse stops the oxytocin and starts oxygen.
After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20 second duration.
Which intervention should the nurse implement?
Stop oxygen per cannula.
Check for clonus in both feet.
Notify nursery about the client's response.
Restart oxytocin infusion rate per protocol.
The Correct Answer is D
Stopping oxygen per cannula after uterine hyperstimulation and subsequent contraction reduction is not appropriate. Oxygen should be continued to ensure fetal oxygenation, particularly after a period of stress caused by frequent contractions. Discontinuing oxygen too soon may compromise fetal well-being.
Choice B rationale
Checking for clonus in both feet is unrelated to the management of uterine contractions post-oxytocin administration. Clonus assessment is used in evaluating neuromuscular function, often in conditions such as preeclampsia, but not for monitoring uterine activity or response to oxytocin.
Choice C rationale
Notifying the nursery about the client's response is important for continuity of care but does not address the immediate need to manage the uterine contractions. The primary focus should be on stabilizing uterine activity before updating other departments.
Choice D rationale
Restarting the oxytocin infusion rate per protocol is the correct intervention after ensuring that the contractions have reduced to a safe frequency and duration. This approach helps to maintain labor progress while minimizing the risk of hyperstimulation and fetal distress. The nurse should follow the hospital's guidelines for oxytocin titration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Low back pain with pelvic cramping can indicate complications such as premature labor or an infection after an amniocentesis.
Choice A rationale
Increased fetal movement is not typically a sign of complications following amniocentesis and may be a normal finding.
Choice B rationale
Headache and blurred vision are concerning symptoms but are not directly related to amniocentesis complications.
Choice C rationale
Epigastric pain can be a sign of other issues, such as preeclampsia, but not specifically related to amniocentesis complications. .
Correct Answer is D
Explanation
Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.
Choice B rationale
Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.
Choice C rationale
Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.
Choice D rationale
Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.
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