The laboring patient is being augmented with oxytocin and is experiencing contractions every 3-4 minutes lasting 60 seconds. The patient's fetal heart rate is ranging from 130-140 beats per minute (BPM) with moderate variability of 6-10 beats per minute. No decelerations are noted. Which action by the nurse is most appropriate?

Insert an internal fetal scalp electrode monitor

Contact the doctor at once and reposition the patient

Document the finding in the patient's medical record

Discontinue the IV fluid containing Pitocin (oxytocin)

Answer and Explanation

The Correct Answer is C

A. Insert an internal fetal scalp electrode monitor. There is no indication for an internal fetal monitor, as the external monitoring shows a reassuring fetal heart rate pattern with moderate variability and no decelerations. Internal monitoring is typically used when external monitoring is inadequate or when fetal distress is suspected.

B. Contact the doctor at once and reposition the patient. There is no fetal distress or abnormal contraction pattern requiring immediate physician intervention. The fetal heart rate is within the normal range (110-160 bpm), and moderate variability indicates adequate oxygenation.

C. Document the finding in the patient's medical record. This is the correct action because the assessment findings indicate a well-oxygenated fetus and a normal labor progression. Contractions every 3-4 minutes lasting 60 seconds are within the expected range for oxytocin augmentation, and no abnormalities are present.

D. Discontinue the IV fluid containing Pitocin (oxytocin). There is no need to stop the oxytocin infusion, as the contraction pattern is appropriate, and there are no signs of uterine tachysystole or fetal distress.

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Correct Answer is B

Explanation

A. Oral hypoglycemic medications. While some oral hypoglycemic agents, such as metformin or glyburide, are used in gestational diabetes, the first-line treatment is always dietary modification and exercise. Medications are only introduced if blood glucose levels remain uncontrolled with lifestyle changes.

B. Diet control and exercise. The initial treatment for gestational diabetes focuses on controlling blood glucose through dietary adjustments, portion control, and regular physical activity. If lifestyle modifications fail to maintain glucose levels within the target range, insulin or oral medications may be introduced.

C. Inhaled insulin. Inhaled insulin is not commonly used in pregnancy because its safety and efficacy for gestational diabetes have not been well established. Insulin therapy, if needed, is typically administered via subcutaneous injection rather than inhalation.

D. Regular insulin injections. Insulin therapy is considered if diet and exercise alone fail to control blood glucose levels. However, it is not the first-line treatment, as many women can successfully manage gestational diabetes without requiring insulin therapy.

A. Perform vaginal exam and apply upward digital pressure to the presenting part. B. Immediately turn the client to her side. C. Call the physician immediately. D. Place a moist, clean towel over the cord to prevent drying.

Correct Answer is A

Explanation

A. Perform vaginal exam and apply upward digital pressure to the presenting part. A prolapsed umbilical cord is an obstetric emergency that can lead to cord compression and fetal hypoxia. The priority intervention is for the nurse to manually lift the presenting part (usually the fetal head) off the cord to relieve pressure and restore blood flow. The nurse should maintain this position until an emergency cesarean section is performed.

B. Immediately turn the client to her side. Positioning changes, such as the knee-chest or Trendelenburg position, can help relieve pressure on the cord, but they are secondary to manually lifting the presenting part. While turning the client may assist, it is not the most immediate life-saving action.

C. Call the physician immediately. While notifying the provider is essential, relieving pressure on the umbilical cord takes priority. Delaying intervention to make a call could result in prolonged fetal hypoxia and compromise.

D. Place a moist, clean towel over the cord to prevent drying. Covering the cord with a moist towel helps prevent vasospasm and drying, but it does not relieve the compression that is cutting off oxygen to the fetus. The priority is to relieve pressure on the cord first before taking other measures.

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Naxlex Comprehensive Predictor Exams

A woman who is 26 weeks pregnant has just found out that she has gestational diabetes. Which of the following therapies will most likely be ordered first for this patient?

Correct Answer is B

Explanation

The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform a vaginal examination. The priority intervention is to:

Correct Answer is A

Explanation

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A laboring woman with Type 1 diabetes is on an IV insulin drip, and the nurse is monitoring her glucose levels hourly. The woman's partner asks why the glucose needs to remain between 70-110 mg/dL. The nurse's response is based on which of the following information?

During a vaginal delivery the midwife tells you that a shoulder dystocia has occurred. Which of the following initial nursing actions is appropriate at this time?

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