A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse's initial action?
Stop the oxytocin infusion.
Turn her on her left side and reassess the contractions.
Continue the infusion and report the findings to the physician.
Administer oxygen by mask.
The Correct Answer is A
A. Stop the oxytocin infusion: Oxytocin should be stopped immediately to prevent hyperstimulation of the uterus, which can lead to fetal distress or uterine rupture.
B. Turn her on her left side and reassess the contractions: While this position can improve fetal oxygenation, it does not address the root cause, which is uterine hyperstimulation.
C. Continue the infusion and report the findings to the physician: Unsafe action as uterine hyperstimulation poses significant risks.
D. Administer oxygen by mask: Oxygen may be needed but is not the priority. Stopping the oxytocin is the first step.
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Related Questions
Correct Answer is D
Explanation
A. Frequency and duration of contractions: Heavy bleeding without contractions is not typically caused by labor. This option is irrelevant to the client’s current condition.
B. Fetal lung maturity: While fetal lung maturity is essential, it is unrelated to the client's heavy vaginal bleeding.
C. Rh incompatibility: This condition does not present with sudden, heavy vaginal bleeding in the third trimester.
D. Location of the placenta: Heavy, painless vaginal bleeding in late pregnancy can indicate placenta previa. Ultrasound is essential to assess placental location to rule out this potentially life-threatening condition.
Correct Answer is B
Explanation
A. “We have a neonatal unit here equipped to handle emergencies.” While reassuring, it does not address the client’s emotions and may seem dismissive.
B. “You must be feeling very scared.” Acknowledges and validates the client’s emotions, fostering therapeutic communication.
C. “You are far enough along that your baby will be just fine.” Provides false reassurance without specific evidence, which is not appropriate.
D. “Everyone worries about their baby while they are in labor.” Generalizes the client’s feelings and may minimize their concerns.
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