A term multigravida, who is receiving oxytocin for labor augmentation, is requesting pain medication. Review of the client's record indicates that she was medicated 30 minutes ago with butorphanol tartrate 2 mg IV push and promethazine 25 mg IV push. Vaginal examination reveals that the client's cervical dilation is 3 cm, 70% effaced, and at a 0 station. Which action should the nurse implement?

Notify the healthcare provider.

Instruct the client to use deep breathing during a contraction.

Discontinue the oxytocin infusion.

Medicate the client with an additional 1 mg of butorphanol tartrate IV push.

Answer and Explanation

The Correct Answer is B

A. Notify the healthcare provider: There's no immediate need to notify the healthcare provider as the client is still in early labor, and pain relief can be managed with non-pharmacological methods.

B. Instruct the client to use deep breathing during a contraction: Non-pharmacological techniques, like deep breathing, should be used first to manage pain, allowing time for the medication effects to take place.

C. Discontinue the oxytocin infusion: The oxytocin infusion is still appropriate as labor is progressing, and there are no signs of complications.

D. Medicate the client with an additional 1 mg of butorphanol tartrate IV push: The client has already been medicated recently, so additional doses could lead to excessive sedation. Waiting for current medication effects is safer.

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Correct Answer is C

Explanation

A. Maternal apical heart rate: While monitoring the maternal heart rate is important, the primary concern in this scenario is the timing of the oxytocin infusion in relation to the onset of bleeding. The time of the infusion helps determine if there is a correlation with the excessive bleeding.

B. Maternal blood pressure: Blood pressure is important for assessing hemodynamic stability, especially in cases of hemorrhage, but the most important immediate information would be related to the timing of the oxytocin infusion, as this could help determine if it is a contributing factor to the bleeding.

C. Time oxytocin infusion completed: The timing of the oxytocin infusion is the most important piece of information to provide. If the bleeding began after the infusion, the healthcare provider can consider oxytocin as a potential cause of uterine atony or other complications.

D. Total amount of oxytocin infused: While the total amount of oxytocin administered is important, the timing of the infusion is more critical in understanding the connection between the oxytocin administration and the onset of bleeding.

A. It is necessary to remain in a side lying position. B. The baby can no longer be born vaginally. C. A cesarean section is the safest route for the baby. D. An explanation will be provided after the delivery.

Correct Answer is C

Explanation

A. It is necessary to remain in a side lying position: While positioning is important to relieve pressure on the cord, this is not the main concern for the client at this moment. The focus should be on explaining why a cesarean section is necessary for the baby's safety.

B. The baby can no longer be born vaginally: While this may be true in the case of a prolapsed cord, it may increase the client's fear unnecessarily. Instead, the nurse should focus on reassuring the client that a cesarean section is being done to ensure the safety of the baby.

C. A cesarean section is the safest route for the baby: This statement reassures the client that the emergency cesarean section is being performed for the safety of the baby, which can help reduce anxiety and confusion about the situation.

D. An explanation will be provided after the delivery: Delaying the explanation until after delivery can increase the client's anxiety. Providing clear, immediate information helps alleviate fear and empowers the client in the situation.

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Naxlex Comprehensive Predictor Exams

A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV oxytocin is infused. When notifying the healthcare provider of the client's condition, which information is most important for the nurse to provide?

Correct Answer is C

Explanation

A client with a prolapsed cord is being prepared for an emergency cesarean section and is expressing fear about the sudden change in delivery method. Which information should the nurse provide?

Correct Answer is C

Explanation

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A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

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