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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Administer oxygen using a non-rebreather mask: Oxygen may be helpful later, but positioning improves uteroplacental perfusion first.

B. Elevate the client’s legs: This addresses maternal hypotension but is less effective for repositioning uterine pressure.

C. Place the client in the lateral position: Lateral positioning improves uteroplacental blood flow and is the priority intervention for late decelerations.

D. Increase the rate of the maintenance IV infusion: Increasing fluids may help, but positioning should be done first.

A. An external fetal monitor will be used to monitor the FHR B. The client will receive an ultrasound prior to the test. C. An IV will be initiated prior to the test. D. The client will be asked to stimulate her nipples for 5 min during the test.

Correct Answer is A

Explanation

A. An external fetal monitor will be used to monitor the FHR: Nonstress tests (NST) monitor the fetal heart rate (FHR) in response to fetal movements using external monitors.

B. The client will receive an ultrasound prior to the test: An ultrasound is not part of the standard procedure for an NST.

C. An IV will be initiated prior to the test: An IV is unnecessary; the test is noninvasive.

D. The client will be asked to stimulate her nipples for 5 min during the test: Nipple stimulation is part of a contraction stress test, not an NST.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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