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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Excessive uterine enlargement: Uterine size is often larger than expected for gestational age due to abnormal tissue growth and fluid accumulation.
B. Whitish vaginal discharge: Not associated with hydatidiform mole.
C. Fetal heart rate irregularities: Hydatidiform mole typically lacks a viable fetus, so no fetal heart rate is detected.
D. Rapidly dropping human chorionic gonadotropin (hCG) levels: hCG levels are elevated in hydatidiform mole, not dropping.
Correct Answer is C
Explanation
A. Cover the cord with a sterile, moist saline dressing: While necessary to prevent cord drying, the first priority is to relieve pressure on the cord.
B. Explain to the client what is happening: Providing information is important but not the priority in an emergency.
C. Place the client in a knee-chest or Trendelenburg position: This action uses gravity to relieve pressure on the umbilical cord, promoting fetal oxygenation.
D. Prepare the client for an emergency cesarean birth: This is necessary but secondary to ensuring immediate cord decompression.
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