Intrauterine resuscitation for an evolving category II or category III tracing includes (Select all that apply):
Go to break
Apply 100% non-rebreather mask
Give an IV fluid bolus
Reposition the mother
Increase the oxytocin drip
Decrease or stop the oxytocin
Correct Answer : B,C,D,F
Choice A: Go to break is not an appropriate action, as it can delay the necessary interventions and compromise the fetal well-beinG. The nurse should stay with the mother and monitor the fetal heart rate and the uterine activity continuously.
Choice B: Apply 100% non-rebreather mask is an appropriate action, as it can increase the maternal oxygenation and improve the fetal oxygen delivery. The nurse should place a mask with a reservoir bag over the mother's nose and mouth and adjust the flow rate to 10 to 15 L/min.
Choice C: Give an IV fluid bolus is an appropriate action, as it can increase the maternal blood volume and improve the uterine perfusion. The nurse should administer 500 to 1000 mL of isotonic crystalloid solution rapidly through a large-bore IV catheter.
Choice D: Reposition the mother is an appropriate action, as it can relieve the uterine or cord compression and improve the fetal circulation. The nurse should turn the mother to the left or right lateral position or place her in a knee-chest position.
Choice E: Increase the oxytocin drip is not an appropriate action, as it can increase the uterine contractions and reduce the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
Choice F: Decrease or stop the oxytocin is an appropriate action, as it can decrease the uterine contractions and increase the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: At least you are young and can have another child is not a therapeutic response, as it minimizes the patient's grief and implies that the baby is replaceablE. The nurse should acknowledge the patient's loss and avoid making assumptions or judgments.
Choice B: I am so sorry for your loss. My heart hurts for you. Can you tell me a little bit about your baby? is a therapeutic response, as it expresses empathy and compassion and invites the patient to share their feelings and memories. The nurse should listen actively and respectfully and use the baby's name if the patient has given onE.
Choice C: There was probably something wrong and God has a way of taking care of these things is not a therapeutic response, as it rationalizes the patient's loss and imposes the nurse's religious beliefs. The nurse should respect the patient's spirituality and avoid making statements that may cause guilt or anger.
Choice D: Don't cry, be strong for your family is not a therapeutic response, as it discourages the patient from expressing their emotions and places unrealistic expectations on them. The nurse should support the patient's coping and encourage them to seek help from their family and friends.
Correct Answer is C
Explanation
Choice A: Polyhydramnios is not a cause of variable decelerations. Polyhydramnios is a condition where there is an excessive amount of amniotic fluid, which can cause complications such as preterm labor, placental abruption, and cord prolapsE. Polyhydramnios can cause late decelerations, which are a sign of uteroplacental insufficiency and fetal hypoxiA.
Choice B: Fetal head compression is not a cause of variable decelerations. Fetal head compression is a normal physiological response to the uterine contractions and the descent of the fetal head into the pelvis. Fetal head compression can cause early decelerations, which are a benign and reassuring pattern that mirror the contractions.
Choice C: Umbilical cord compression is a cause of variable decelerations. Umbilical cord compression is a condition where the blood flow through the umbilical cord is reduced or interrupted, which can result from cord prolapse, cord knots, or cord wrapping around the fetal neck or limbs. Umbilical cord compression can cause variable decelerations, which are abrupt and irregular decreases in the FHR that vary in shape, duration, and timinG.
Choice D: Maternal fever is not a cause of variable decelerations. Maternal fever is a condition where the mother's body temperature is elevated, which can indicate an infection or inflammation. Maternal fever can cause tachycardia, which is a high FHR above the normal range of 110 to 160 beats/min.
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