The nurse has administered Oxytocin 2 hours ago as ordered. The nurse is assessing the fetal heart tracing: baseline 120 with moderate variability and 1 variable deceleration down to 80 bpm followed by a prolonged deceleration. There are 8 contractions in 10 minutes lasting 40-60 seconds. What is the nurse's initial intervention?
Perform fetal scalp stimulation
Apply oxygen
Discontinue Pitocin
Administer IV bolus
The Correct Answer is C
Choice A reason: Fetal scalp stimulation is used to assess fetal responsiveness when variability is minimal. It is not appropriate as an initial intervention in the presence of tachysystole and prolonged decelerations.
Choice B reason: Applying oxygen can improve maternal oxygenation and fetal oxygen delivery, but it is not the first step when uterine hyperstimulation is present.
Choice C reason: Discontinuing Pitocin is the priority intervention. The client is experiencing uterine tachysystole (8 contractions in 10 minutes), which compromises fetal oxygenation and is associated with prolonged decelerations. Stopping Pitocin reduces uterine activity and allows fetal recovery.
Choice D reason: Administering an IV bolus may help improve uteroplacental perfusion, but it is secondary to stopping the source of overstimulation (Pitocin).
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Warm water increases circulation and milk flow, which worsens engorgement in non-breastfeeding mothers.
Choice B reason: Expressing milk stimulates further milk production, prolonging engorgement. This is contraindicated for mothers who are bottle feeding.
Choice C reason: A loose-fitting bra does not provide adequate support. A snug, supportive bra is recommended to minimize discomfort and reduce stimulation.
Choice D reason: Applying ice reduces swelling, inflammation, and discomfort. Cold compresses help suppress milk production and relieve engorgement in bottle-feeding mothers.
Correct Answer is D
Explanation
Choice A reason: Intermittent fetal heart auscultation is appropriate when contractions are infrequent and the fetal heart rate is reassuring. It allows monitoring without continuous electronic fetal monitoring, especially in low-risk cases.
Choice B reason: Nipple stimulation is a natural method to promote uterine contractions by stimulating endogenous oxytocin release. However, in this case, contractions are already present, and nipple stimulation is not contraindicated.
Choice C reason: Administration of IV fluids is safe and often necessary to maintain hydration, support uteroplacental perfusion, and prevent maternal hypotension.
Choice D reason: Vaginal examinations every hour are contraindicated because the client has had ruptured membranes for 18 hours. Frequent vaginal exams increase the risk of ascending infection (chorioamnionitis). Vaginal exams should be minimized and performed only when clinically indicated.
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