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
Correct Answer is D
Explanation
Choice A: Absence of family members during labor is not a common practice among Hispanic clients, as they tend to value family support and involvement during childbirtH. The nurse should respect the client's preferences and allow the family members to be present if the client wishes.
Choice B:Traditionally, Hispanic postpartum practices emphasize warmth and avoidance of cold. Cold fluids are generally discouraged, as cultural beliefs hold that they may cause imbalance or illness. Thus, requesting cold fluids immediately after delivery is unlikely.
Choice C: Practice of maternal fasting following the birth is not a common practice among Hispanic clients, as they tend to consume warm and nutritious foods and beverages to promote healing and lactation. The nurse should encourage the client to eat a balanced diet and provide culturally appropriate foods if possiblE.
Choice D: Delaying breastfeeding for several days is a recognized cultural practice among some Hispanic families. Colostrum may be viewed as “dirty” or insufficient, and mothers may wait until mature milk comes in before initiating breastfeeding. Nurses should anticipate this belief and provide culturally sensitive education about the benefits of early breastfeeding while respecting the client’s values.
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