The nurse is caring for a term client in labor receiving oxytocin to induce contractions and notes 6 contractions in a 10-minute period.
The nurse palpates the resting tone and notes it to be non-relaxed.
What is the next intervention the nurse could perform?
Notify the provider stat for a bedside consult.
Decrease the oxytocin rate on the pump by half.
Prepare the room for impending delivery of the fetus.
Place oxygen via a non-rebreather at 10L/min.
The Correct Answer is B
Choice A rationale
Notifying the provider stat is an appropriate action but it is not the immediate next step. The nurse must first implement interventions to address the uterine tachysystole and hypertonicity, which are causing a non-reassuring fetal status. The primary action is to stop the oxytocin to prevent further stress on the fetus.
Choice B rationale
The nurse should decrease the oxytocin rate because the client is experiencing uterine tachysystole, defined as more than five contractions in 10 minutes, and hypertonicity, indicated by the non-relaxed resting tone. This condition reduces uterine blood flow and oxygen to the fetus, so decreasing the oxytocin is the most immediate intervention to correct the problem.
Choice C rationale
Preparing the room for delivery is not an appropriate action at this time. The current issue is uterine tachysystole and hypertonicity, which indicates a risk to fetal well-being, not that delivery is imminent. The priority is to resolve the uterine overstimulation and reassess fetal tolerance of labor before considering delivery.
Choice D rationale
Placing oxygen is a supportive measure but not the primary intervention. While oxygen may help improve fetal oxygenation, the root cause is the excessive uterine activity, which is best addressed by decreasing or stopping the oxytocin infusion. Addressing the primary cause is the priority before implementing supportive measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
A previous classical cesarean incision is a significant contraindication for a contraction stress test (CST). The CST involves inducing uterine contractions, which can place stress on the myometrial scar from the previous surgery. The risk of uterine rupture is significantly increased with a classical incision (vertical uterine cut), which could lead to severe maternal hemorrhage and fetal demise.
Choice A rationale
Decreased fetal movement is an indication, not a contraindication, for a contraction stress test. When a biophysical profile (BPP) score is concerning (e.g., 6/8), further evaluation is warranted to assess fetal well-being. A CST is often used in this scenario to determine if the fetus can tolerate the stress of labor, providing valuable information for obstetrical management.
Choice B rationale
Gestational diabetes is not a contraindication for a contraction stress test. Instead, it is a common reason why a CST may be performed. Poorly controlled gestational diabetes can lead to macrosomia, polyhydramnios, and fetal compromise, all of which necessitate closer fetal surveillance. A CST helps assess for placental insufficiency in these high-risk pregnancies.
Choice C rationale
Oligohydramnios, or low amniotic fluid, is a common indication for a contraction stress test, not a contraindication. Oligohydramnios is often associated with placental insufficiency, which can lead to poor fetal growth and umbilical cord compression. The CST is used to evaluate the fetus's ability to withstand contractions and to assess the adequacy of placental func
Correct Answer is A
Explanation
Choice A rationale
A reactive Non-Stress Test is a positive indicator of fetal health and a well-oxygenated central nervous system. This is defined by the occurrence of at least two fetal heart rate accelerations, each peaking at 15 beats per minute above the baseline and lasting for 15 seconds, within a 20-minute period. This response confirms a healthy, non-compromised fetus.
Choice B rationale
A non-reactive Non-Stress Test, not a reactive one, would indicate potential fetal distress or insufficient oxygenation. A reactive NST shows a healthy, active fetus with a heart rate that responds appropriately to its own movements, which is a sign of good fetal oxygenation and a healthy nervous system.
Choice C rationale
The criteria for a reactive NST in a fetus at 34 weeks or more is an acceleration of at least 15 beats per minute above the baseline, lasting for 15 seconds. The 10 beats per minute by 10 seconds criterion applies to fetuses less than 32 weeks, reflecting a less mature nervous system.
Choice D rationale
The Non-Stress Test (NST) is named such because it does not involve the use of uterine contractions to assess fetal response. This describes a Contraction Stress Test (CST) or an Oxytocin Challenge Test, which specifically evaluates the fetal heart rate response to uterine contractions to assess placental reserve. *.
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