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 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.

A. No action is necessary since a decrease in the woman's blood pressure is expected. B. Decrease her intravenous (IV) rate to a keep vein-open rate. C. Encourage her to empty her bladder. D. Turn the woman to the left lateral position or place a pillow under her hip.

Correct Answer is D

Explanation

A. No action is necessary since a decrease in the woman's blood pressure is expected. While a drop in blood pressure is a common side effect of a spinal block, a 20% decrease is significant and can compromise placental perfusion, leading to fetal distress. Intervention is necessary to restore circulation.

B. Decrease her intravenous (IV) rate to a keep vein-open rate. This is incorrect because IV fluids help counteract hypotension. Instead of decreasing the IV rate, the nurse may need to increase fluid administration to improve blood pressure and maintain perfusion.

C. Encourage her to empty her bladder. A full bladder can affect labor progression but does not directly cause or correct hypotension. The priority in this scenario is restoring blood pressure to ensure adequate fetal oxygenation.

D. Turn the woman to the left lateral position or place a pillow under her hip. This is the most appropriate intervention. A left lateral position or elevating her right hip helps relieve aortocaval compression, improving blood flow to the uterus and stabilizing blood pressure. Additional interventions, such as IV fluid boluses or vasopressors (e.g., ephedrine), may be needed if hypotension persists.

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Naxlex Comprehensive Predictor Exams

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

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?

Correct Answer is D

Explanation

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The nurse would include which of the following statements when describing the pathophysiology of gestational diabetes?

A patient is being discharged from the hospital after the evacuation of a molar pregnancy. The nurse recognizes that additional discharge teaching is required when the patient makes which statement?

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The nurse recognizes that a woman is in true labor when she states…., and finds that her cervix has dilated and effaced on examination.

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