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 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.

A. Cover the cord with a sterile, moist saline dressing B. Explain to the client what is happening. C. Place the client in a knee-chest or Trendelenburg position. D. Prepare the client for an emergency cesarean birth.

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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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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