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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Limit sodium intake to 2,000 mg/day: Sodium restriction is not recommended for preeclampsia as it does not prevent the condition and may cause volume depletion.
B. Limit fluid intake to 1,000 mL/day: Fluid restriction is not recommended unless there are signs of fluid overload or pulmonary edema.
C. Rest in bed in the supine position: Supine positioning can compromise uteroplacental perfusion; left lateral positioning is preferred.
D. Perform daily fetal movement counts: Monitoring fetal movements helps assess fetal well-being and detect potential complications.
Correct Answer is A
Explanation
A. Ineffective coping related to inadequate preparation for labor: This addresses the client’s inability to manage labor effectively due to a lack of childbirth preparation, as evidenced by her emotional distress.
B. Pain related to uterine contractions: While pain is present, addressing ineffective coping takes precedence because it impacts how the client handles labor and her perception of pain.
C. Risk for injury related to lack of prenatal care: This is important but not immediately relevant to her current emotional state and pain management needs.
D. Knowledge deficit related to the birth experience: While true, the immediate priority is the client's emotional and coping response.
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